MEDICARE: MARK N. MONTGOMERY, D.D.S., INC.

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	31673	CA

General Provider Information

NPI Number	:	1952510067
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK N. MONTGOMERY, D.D.S., INC.

Provider Business Mailing Address
First Line	:	32241 CROWN VALLEY PKWY
Second Line	:	SUITE 240
City	:	MONARCH BEACH
State	:	CA
Zip	:	92629-3346
Country	:	US
Telephone Number	:	949-493-3333
Fax Number	:	949-493-2057

Provider Business Practice Location Address
First Line	:	32241 CROWN VALLEY PKWY
Second Line	:	SUITE 240
City	:	MONARCH BEACH
State	:	CA
Zip	:	92629-3346
Country	:	US
Telephone Number	:	949-493-3333
Fax Number	:	949-493-2057

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK N. MONTGOMERY
Credential	:	D.D.S.
Telephone Number	:	949-493-3333

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	08/22/2020

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