Provider Demographics
NPI:1861520595
Name:MONTGOMERY, MICHELLE YVONNE (RDH, RDHAP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:YVONNE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:RDH, RDHAP
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 16582
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91416-6582
Mailing Address - Country:US
Mailing Address - Phone:310-743-4374
Mailing Address - Fax:
Practice Address - Street 1:18163 WELBY WAY
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-5522
Practice Address - Country:US
Practice Address - Phone:310-743-4374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP37124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist