Healthcare Provider Details

I. General information

NPI: 1760583231
Provider Name (Legal Business Name): ALAN B MONTGOMERY ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4535 HODGSON RD 700
SHOREVIEW MN
55126
US

IV. Provider business mailing address

4535 HODGSON RD 700
SHOREVIEW MN
55126
US

V. Phone/Fax

Practice location:
  • Phone: 651-765-1945
  • Fax: 651-765-1949
Mailing address:
  • Phone: 651-765-1945
  • Fax: 651-765-1949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1442499921
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD3327
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8584
License Number StateMN

VIII. Authorized Official

Name: DR. ALAN B MONTGOMERY
Title or Position: OWNER
Credential: DDS MS
Phone: 651-765-1945