Healthcare Provider Details

I. General information

NPI: 1063744829
Provider Name (Legal Business Name): MELANIE A CLARY RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 02/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 28038
APO AE
09112-5000
US

IV. Provider business mailing address

CMR 459 BOX 17911
APO AE
09139
US

V. Phone/Fax

Practice location:
  • Phone: 314-476-4738
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number9203298
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number8417
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number983
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: