MEDICARE: DR. MELANIE C DETWEILER D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401412489	VA

General Provider Information

NPI Number	:	1689807109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MELANIE C DETWEILER D.D.S.

Provider Business Mailing Address
First Line	:	3643 SEA BREEZE CIR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-4736
Country	:	US
Telephone Number	:	757-679-8914
Fax Number	:

Provider Business Practice Location Address
First Line	:	4530 PROFESSIONAL CIR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-6441
Country	:	US
Telephone Number	:	757-499-0567
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2009
Last Update Date	:	04/05/2016

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