Healthcare Provider Details

I. General information

NPI: 1730509266
Provider Name (Legal Business Name): KATIE L. MELKO RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 BIRCHWOOD RD
SEYMOUR CT
06483-3806
US

IV. Provider business mailing address

78 BIRCHWOOD RD
SEYMOUR CT
06483-3806
US

V. Phone/Fax

Practice location:
  • Phone: 203-305-7791
  • Fax:
Mailing address:
  • Phone: 203-305-7791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number007529
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: