Healthcare Provider Details

I. General information

NPI: 1851994958
Provider Name (Legal Business Name): MELISSA PHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 STATE ROAD 13
JACKSONVILLE FL
32259-3838
US

IV. Provider business mailing address

1357 MARSH GRASS CT
JACKSONVILLE FL
32218-8646
US

V. Phone/Fax

Practice location:
  • Phone: 904-209-6590
  • Fax:
Mailing address:
  • Phone: 773-742-4164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number27900
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: