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General NPI Number Information
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NPI Number | 1053409490
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Entity Type | Organization
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Legal Business Name | THE BLEVINS LEGACY DENTAL
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 148 STATE ROUTE 775
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City | PROCTORVILLE
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State | OH
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Zip | 45669-8839
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Country | US
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Telephone | 740-886-7000
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Fax | 740-886-5518
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Provider Business Mailing Address
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Address Line | PO BOX 459
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City | PROCTORVILLE
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State | OH
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Zip | 45669-0459
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Country | US
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Telephone | 740-886-7000
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Fax | 740-886-5518
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. MELANIE LYNN BLEVINS
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Credential | D.D.S.
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Telephone | 740-886-7000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3484
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 21386
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License Number State | OH
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