=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174778435
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAWRENCE PURVES MONTGOMERY III DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2008
-----------------------------------------------------
Last Update Date | 11/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3401 MARKET ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-3318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-573-8400
-----------------------------------------------------
Fax | 215-573-5550
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3797 SUMMIT LN
-----------------------------------------------------
City | CHALFONT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18914-3497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-920-2723
-----------------------------------------------------
Fax | 215-822-5214
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS-023070-L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------