Healthcare Provider Details

I. General information

NPI: 1063773513
Provider Name (Legal Business Name): MELISSA FLYNN D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 S RICHARDS AVE
SANTA FE NM
87508-4887
US

IV. Provider business mailing address

6401 S RICHARDS AVE
SANTA FE NM
87508-4887
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-4425
  • Fax:
Mailing address:
  • Phone: 505-982-4425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3094
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN20525
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDB-2024-0097
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: