Healthcare Provider Details

I. General information

NPI: 1205187143
Provider Name (Legal Business Name): MELANIE HOLDEN, DMD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 SW MAIN BLVD
LAKE CITY FL
32025-7050
US

IV. Provider business mailing address

255 SW MAIN BLVD
LAKE CITY FL
32025-7050
US

V. Phone/Fax

Practice location:
  • Phone: 386-752-2480
  • Fax:
Mailing address:
  • Phone: 386-752-2480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN19370
License Number StateFL

VIII. Authorized Official

Name: MELANIE HOLDEN
Title or Position: SOLE MBR
Credential: DMD
Phone: 386-752-2480