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General NPI Number Information
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NPI Number | 1316151202
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Entity Type | Organization
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Legal Business Name | MONTGOMERY RADIOGRAPHIC SVS
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Dates
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Enumeration Date | 05/09/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 720 N TUSTIN AVE STE 204
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City | SANTA ANA
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State | CA
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Zip | 92705-3606
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Country | US
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Telephone | 714-835-7260
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Fax | 714-835-5808
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Provider Business Mailing Address
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Address Line | 720 N TUSTIN AVE 204
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City | SANTA ANA
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State | CA
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Zip | 92705
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Country | US
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Telephone | 714-835-7260
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Fax | 714-835-5808
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Authorized Official
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Title or Position | OWNER XRAY TECHNICIAN
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Name | MR. MONTE MATTHEW MONTGOMERY
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Credential | XRAY TECHNICIAN
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Telephone | 714-835-7260
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0008X
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Taxonomy Name | Oral and Maxillofacial Radiology Dentistry
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License Number | RHP 52036
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License Number State | CA
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