Healthcare Provider Details

I. General information

NPI: 1073028221
Provider Name (Legal Business Name): MELVIN GERALD MARKHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26108 HIGHWAY 189
TWIN PEAKS CA
92391
US

IV. Provider business mailing address

PO BOX D
TWIN PEAKS CA
92391-0280
US

V. Phone/Fax

Practice location:
  • Phone: 909-337-2013
  • Fax:
Mailing address:
  • Phone: 909-337-2013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number27030
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: