Provider Demographics
NPI:1649352113
Name:MONTGOMERY, MARLIN M (DDS)
Entity type:Individual
Prefix:DR
First Name:MARLIN
Middle Name:M
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8310
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0390
Mailing Address - Country:US
Mailing Address - Phone:541-469-5371
Mailing Address - Fax:541-412-0177
Practice Address - Street 1:565 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9702
Practice Address - Country:US
Practice Address - Phone:541-469-5371
Practice Address - Fax:541-412-0177
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2025-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5448122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR006536Medicaid
OR006536Medicaid