Basic Information
| Provider Information | |||||||||
| NPI: | 1336371988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELANSON | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 GALLERIA PKWY SE | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303395980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709165362 | ||||||||
| FaxNumber: | 6782477829 | ||||||||
| Practice Location | |||||||||
| Address1: | 1923 MARSHA SHARP FWY | ||||||||
| Address2: | 103 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794154036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067446581 | ||||||||
| FaxNumber: | 8067479794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2009 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 24899 | TX | Y | Dental Providers | Dentist | Pediatric Dentistry | 1223G0001X | 24899 | TX | N | Dental Providers | Dentist | General Practice |
No ID Information.