Healthcare Provider Details

I. General information

NPI: 1770812018
Provider Name (Legal Business Name): ALAN B MONTGOMERY D.D.S, M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2009
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4535 HODGSON RD #700
SHOREVIEW MN
55126-1949
US

IV. Provider business mailing address

4535 HODGSON RD #700
SHOREVIEW MN
55126-1949
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 TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD8584
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: