MEDICARE: DR. MELISSA CANDELLA HOLT 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	DS038436	PA
2	390200000X	Student in an Organized Health Care Education/Training Program
3	122300000X	Dentist	DS038436	PA

General Provider Information

NPI Number	:	1053632000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MELISSA CANDELLA HOLT DMD

Provider Business Mailing Address
First Line	:	2133 PEPPERRELL ST
Second Line	:
City	:	LACKLAND AFB
State	:	TX
Zip	:	78236-5313
Country	:	US
Telephone Number	:	210-292-7775
Fax Number	:

Provider Business Practice Location Address
First Line	:	2133 PEPPERRELL ST
Second Line	:
City	:	LACKLAND AFB
State	:	TX
Zip	:	78236-5313
Country	:	US
Telephone Number	:	210-292-7775
Fax Number	:

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

Provider Enumeration Date	:	06/14/2010
Last Update Date	:	08/16/2021

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