MEDICARE: MICHAEL MONTGOMEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	29383	CA

General Provider Information

NPI Number	:	1073965216
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL MONTGOMEY

Provider Business Mailing Address
First Line	:	8055 W MANCHESTER AVE
Second Line	:	SUITE 500
City	:	PLAYA DEL REY
State	:	CA
Zip	:	90293-7960
Country	:	US
Telephone Number	:	310-821-0992
Fax Number	:

Provider Business Practice Location Address
First Line	:	8055 W MANCHESTER AVE
Second Line	:	SUITE 500
City	:	PLAYA DEL REY
State	:	CA
Zip	:	90293-7960
Country	:	US
Telephone Number	:	310-821-0992
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL MONETGOMERY
Credential	:	DDS
Telephone Number	:	310-821-0992

Provider Enumeration Date	:	07/12/2016
Last Update Date	:	07/12/2016

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