MEDICARE: DR. RANDALL CLINE MONTGOMERY DDS

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	1223G0001X	General Practice Dentistry	4805	TN

General Provider Information

NPI Number	:	1255316154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDALL CLINE MONTGOMERY DDS

Provider Business Mailing Address
First Line	:	2975 FORT HENRY DR
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37664-4005
Country	:	US
Telephone Number	:	423-247-9196
Fax Number	:

Provider Business Practice Location Address
First Line	:	2975 FORT HENRY DR
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37664-4005
Country	:	US
Telephone Number	:	423-247-9196
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2005
Last Update Date	:	07/08/2007

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