=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972606523
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA D PRIMUS DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 03/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5509 YOUNG ST CAL DEPT CORRECTIONS & REHAB DCHCS REGIONIII DENTAL
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93311-9648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-708-6306
-----------------------------------------------------
Fax | 661-664-2563
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9905 LIGHTNER WAY
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-631-9863
-----------------------------------------------------
Fax | 661-663-8345
-----------------------------------------------------
=====================================================
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 | 44434
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------