=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477651131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA MAE DEEG D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 12/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 CARMICHAEL RD SUITE 203
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54016-8269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-381-9710
-----------------------------------------------------
Fax | 715-381-9728
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 131 CARMICHAEL RD SUITE 203
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54016-8269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-381-9710
-----------------------------------------------------
Fax | 715-381-9728
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D11966
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------