1033519012 NPI number — RONALD MONTGOMERY DENTAL GROUP, PC

Table of content: DR. MICHAEL TRAE MATTISON M.D. (NPI 1952411977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033519012 NPI number — RONALD MONTGOMERY DENTAL GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RONALD MONTGOMERY DENTAL GROUP, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033519012
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 SE TECH CENTER DR STE 195
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98683-5511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-869-7645
Provider Business Mailing Address Fax Number:
877-725-7443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1333 N SANTA FE AVE STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73003-3677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-285-7557
Provider Business Practice Location Address Fax Number:
405-285-7130
Provider Enumeration Date:
08/27/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MONTGOMERY
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PC OWNER
Authorized Official Telephone Number:
405-698-1003

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3733 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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