Healthcare Provider Details

I. General information

NPI: 1417095894
Provider Name (Legal Business Name): MELISSA WILSON VENRICK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 17TH AVE STE 103
LONGMONT CO
80501-2647
US

IV. Provider business mailing address

1055 17TH AVE STE 103
LONGMONT CO
80501-2647
US

V. Phone/Fax

Practice location:
  • Phone: 303-651-7771
  • Fax: 303-651-1435
Mailing address:
  • Phone: 303-651-7771
  • Fax: 303-651-1435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7430
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: