Healthcare Provider Details

I. General information

NPI: 1497733588
Provider Name (Legal Business Name): MELESSIA M CONGDON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PARK ST
OLYPHANT PA
18447-1982
US

IV. Provider business mailing address

500 PARK ST
OLYPHANT PA
18447-1982
US

V. Phone/Fax

Practice location:
  • Phone: 570-383-9066
  • Fax: 570-383-4183
Mailing address:
  • Phone: 570-383-9066
  • Fax: 570-383-4183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH068160
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: