Healthcare Provider Details

I. General information

NPI: 1902053259
Provider Name (Legal Business Name): MELBA DIETRICH DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 UNION STREET
LYNN MA
01913-1314
US

IV. Provider business mailing address

269 UNION STREET LYNN COMMUNITY HEALTH CENTER
LYNN MA
01913-1314
US

V. Phone/Fax

Practice location:
  • Phone: 781-596-2502
  • Fax: 781-596-3966
Mailing address:
  • Phone: 781-596-2502
  • Fax: 781-596-3966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10167
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: