MEDICARE: CHILDREN'S DENTAL RANCH OF NEW BRAUNFELS, PLLC

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1558997734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S DENTAL RANCH OF NEW BRAUNFELS, PLLC

Provider Business Mailing Address
First Line	:	505 E HUNTLAND DR. #340
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78752
Country	:	US
Telephone Number	:	512-206-2975
Fax Number	:

Provider Business Practice Location Address
First Line	:	1187 WEST COUNTY LINE RD, SUITE 11B
Second Line	:
City	:	NEW BRAUNFELS
State	:	TX
Zip	:	78130
Country	:	US
Telephone Number	:	512-206-2975
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	DR. MARTY MONTGOMERY
Credential	:	DMD
Telephone Number	:	512-206-2975

Provider Enumeration Date	:	03/19/2020
Last Update Date	:	03/19/2020

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