MEDICARE: DR. NICHOLAS RYAN MELLUM 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	D8836	OR

General Provider Information

NPI Number	:	1053454173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAS RYAN MELLUM DMD

Provider Business Mailing Address
First Line	:	8910 N KELLOGG ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-3002
Country	:	US
Telephone Number	:	503-286-4492
Fax Number	:	503-765-1343

Provider Business Practice Location Address
First Line	:	8910 N KELLOGG ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-3002
Country	:	US
Telephone Number	:	503-286-4492
Fax Number	:

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

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	05/10/2016

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