MEDICARE: MIRANDA JOAN MELVIN DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	30.026506	OH

General Provider Information

NPI Number	:	1023683927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRANDA JOAN MELVIN DMD

Provider Business Mailing Address
First Line	:	804 4TH ST E
Second Line	:
City	:	SOUTH POINT
State	:	OH
Zip	:	45680-9117
Country	:	US
Telephone Number	:	740-377-2020
Fax Number	:	740-377-4961

Provider Business Practice Location Address
First Line	:	804 4TH ST E
Second Line	:
City	:	SOUTH POINT
State	:	OH
Zip	:	45680-9117
Country	:	US
Telephone Number	:	740-377-2020
Fax Number	:	740-377-4961

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2021
Last Update Date	:	05/24/2021

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