Basic Information
| Provider Information | |||||||||
| NPI: | 1548318884 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEINTRAUB | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 ALLENS AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029055010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014440400 | ||||||||
| FaxNumber: | 4014440468 | ||||||||
| Practice Location | |||||||||
| Address1: | 335 PRAIRIE AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029052426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014440430 | ||||||||
| FaxNumber: | 4014440489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 08/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 21227 | MA | N | Dental Providers | Dentist | General Practice | 1223G0001X | DEN03007 | RI | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 30303535 | 05 | NH | MEDICAID | 0208868 | 05 | MA | MEDICAID |