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General NPI Number Information
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NPI Number | 1619631413
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Entity Type | Individual
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Provider Name | MELVIN DAVID PEDERSON JR. DDS
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Gender | Male
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Dates
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Enumeration Date | 10/27/2021
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Last Update Date | 08/29/2023
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Provider Practice Location Address
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Address Line | 15121 E MISSISSIPPI AVE
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City | AURORA
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State | CO
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Zip | 80012-3746
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Country | US
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Telephone | 303-802-1022
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Fax |
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Provider Business Mailing Address
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Address Line | 400 E MAIN ST STE 190
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City | HILLSBORO
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State | OR
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Zip | 97123-4163
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Country | US
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Telephone | 810-287-5361
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DEN.00204856
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | D11868
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DEN.00204856
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License Number State | CO
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