Healthcare Provider Details

I. General information

NPI: 1700965134
Provider Name (Legal Business Name): MICHAEL TODD MONTGOMERY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7551 CALLAGHAN RD #210
SAN ANTONIO TX
78229-2860
US

IV. Provider business mailing address

7551 CALLAGHAN RD #210
SAN ANTONIO TX
78229-2860
US

V. Phone/Fax

Practice location:
  • Phone: 210-308-8228
  • Fax: 210-308-5516
Mailing address:
  • Phone: 210-308-8228
  • Fax: 210-308-5516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14958
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: