Provider Demographics
NPI:1871714766
Name:MONTGOMERY, TYRUS GERARD (DMD)
Entity type:Individual
Prefix:DR
First Name:TYRUS
Middle Name:GERARD
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12300 KEMMERTON LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-2721
Mailing Address - Country:US
Mailing Address - Phone:301-262-1888
Mailing Address - Fax:301-266-1899
Practice Address - Street 1:12300 KEMMERTON LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-2721
Practice Address - Country:US
Practice Address - Phone:301-262-1888
Practice Address - Fax:301-262-1899
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD117131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice