Healthcare Provider Details

I. General information

NPI: 1609442268
Provider Name (Legal Business Name): MELISSA PESTLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3575 KEITH ST NW
CLEVELAND TN
37312-4324
US

IV. Provider business mailing address

3575 KEITH ST NW
CLEVELAND TN
37312-4324
US

V. Phone/Fax

Practice location:
  • Phone: 423-458-6660
  • Fax: 423-339-2095
Mailing address:
  • Phone: 423-458-6660
  • Fax: 423-339-2095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number16971
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: