Healthcare Provider Details

I. General information

NPI: 1447298898
Provider Name (Legal Business Name): MELITA ISLAMBASIC DMD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 KNIGHTS RUN AVE APT 2112
TAMPA FL
33602-5938
US

IV. Provider business mailing address

501 KNIGHTS RUN AVE APT 2112
TAMPA FL
33602-5938
US

V. Phone/Fax

Practice location:
  • Phone: 239-989-4269
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number18058
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: