Basic Information
Provider Information
NPI: 1194939439
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CADDELL
FirstName: MELYNDA
MiddleName: K
NamePrefix:  
NameSuffix:  
Credential: DH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 203 S ROLLIE AVE
Address2:  
City: FORT LUPTON
State: CO
PostalCode: 806211508
CountryCode: US
TelephoneNumber: 3032864560
FaxNumber: 3032864589
Practice Location
Address1: 220 E ROGERS RD
Address2:  
City: LONGMONT
State: CO
PostalCode: 805016027
CountryCode: US
TelephoneNumber: 3037721906
FaxNumber: 3036829269
Other Information
ProviderEnumerationDate: 05/09/2007
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
124Q00000X904283COY Dental ProvidersDental Hygienist 

No ID Information.


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