Basic Information
Provider Information
NPI: 1588912737
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MONTGOMERY
FirstName: QUINN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 145 S BUENA VISTA ST
Address2:  
City: REDLANDS
State: CA
PostalCode: 923735126
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 351 FELICE DR
Address2:  
City: HOLLISTER
State: CA
PostalCode: 950233361
CountryCode: US
TelephoneNumber: 8316375306
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/20/2012
LastUpdateDate: 08/20/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X61804CAY Dental ProvidersDentist 

No ID Information.


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