=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912149980
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW JOHN MELANCON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2009
-----------------------------------------------------
Last Update Date | 06/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 W MADISON ST
-----------------------------------------------------
City | BROUSSARD
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70518-4518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-837-1861
-----------------------------------------------------
Fax | 337-837-1278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 W MADISON ST
-----------------------------------------------------
City | BROUSSARD
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70518-4518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-837-1861
-----------------------------------------------------
Fax | 337-837-1278
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5974
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------