Montgomery Dental Arts, LLC

Contacts

Phone	+1 334-356-0228
Fax	3343560264
Phone	+1 334-398-2907
Fax	6788403982

Authorized person

Name	DR. DOMINIQUE A SHAMBURGER JR.
Role	MBR
Phone	3343560228

Taxonomy

Taxonomy Code	1223G0001X - General Practice Dentistry
Is Primary	Yes
Taxonomy Code	261QD0000X - Dental Clinic/Center
Is Primary	No

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	621210
Sponsor’s telephone number	3343560228
Plan sponsor’s address	10650 CHANTILLY PARKWAY, MONTGOMERY, AL, 36117

Signature of

Role	Plan administrator
Date	2024-07-15
Name of individual signing	CARL SHAMBURGER

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	621210
Sponsor’s telephone number	3343560228
Plan sponsor’s address	10650 CHANTILLY PARKWAY, MONTGOMERY, AL, 36117

Signature of

Role	Plan administrator
Date	2023-07-06
Name of individual signing	CARL SHAMBURGER

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	621210
Sponsor’s telephone number	3343560228
Plan sponsor’s address	10650 CHANTILLY PARKWAY, MONTGOMERY, AL, 36117

Signature of

Role	Plan administrator
Date	2022-05-26
Name of individual signing	CARL SHAMBURGER

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	621210
Sponsor’s telephone number	3343560228
Plan sponsor’s address	10650 CHANTILLY PARKWAY, MONTGOMERY, AL, 36117

Signature of

Role	Plan administrator
Date	2021-06-21
Name of individual signing	CARL SHAMBURGER

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2019-01-01
Business code	621210
Sponsor’s telephone number	3343560228
Plan sponsor’s address	10650 CHANTILLY PARKWAY, MONTGOMERY, AL, 36117

Signature of

Role	Plan administrator
Date	2020-07-06
Name of individual signing	CARL SHAMBURGER