MEDICARE: MELE FAMILY DENTISTRY PC

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	1223P0300X	Periodontics
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1992303945
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MELE FAMILY DENTISTRY PC

Provider Business Mailing Address
First Line	:	40 W EVERGREEN AVE STE 111
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19118-3324
Country	:	US
Telephone Number	:	215-242-9411
Fax Number	:	215-242-3454

Provider Business Practice Location Address
First Line	:	40 W EVERGREEN AVE STE 111
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19118-3324
Country	:	US
Telephone Number	:	215-242-9411
Fax Number	:	215-242-3454

Authorized Official
Title or Position	:	PRESIDENT
Name	:	COREY MELE
Credential	:	DMD
Telephone Number	:	215-520-5051

Provider Enumeration Date	:	10/13/2020
Last Update Date	:	10/13/2020

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