Provider Demographics
NPI:1003130816
Name:MELO, THAIZE LARA (DDS)
Entity Type:Individual
Prefix:
First Name:THAIZE
Middle Name:LARA
Last Name:MELO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NORTH ABERDEEN ST
Mailing Address - Street 2:APARTMENT 405
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2243
Mailing Address - Country:US
Mailing Address - Phone:312-841-2661
Mailing Address - Fax:
Practice Address - Street 1:3 NORTH ABERDEEN ST
Practice Address - Street 2:APARTMENT 405
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2243
Practice Address - Country:US
Practice Address - Phone:312-841-2661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-23
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028216122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist