Healthcare Provider Details

I. General information

NPI: 1104087535
Provider Name (Legal Business Name): MELISSA VETTRAINO D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2546 S BROAD ST
PHILADELPHIA PA
19145-4638
US

IV. Provider business mailing address

2546 S BROAD ST
PHILADELPHIA PA
19145-4638
US

V. Phone/Fax

Practice location:
  • Phone: 215-755-1001
  • Fax: 215-755-1406
Mailing address:
  • Phone: 215-755-1001
  • Fax: 215-755-1406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS037946
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: