Healthcare Provider Details

I. General information

NPI: 1548575236
Provider Name (Legal Business Name): MELISSA RAE COLLETT RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4325 GRAND AVE
DULUTH MN
55807-2730
US

IV. Provider business mailing address

4325 GRAND AVE
DULUTH MN
55807-2730
US

V. Phone/Fax

Practice location:
  • Phone: 218-628-7035
  • Fax: 218-624-6594
Mailing address:
  • Phone: 218-628-7035
  • Fax: 218-624-6594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH8731
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: