Provider Demographics
NPI:1053454173
Name:MELLUM, NICHOLAS RYAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:RYAN
Last Name:MELLUM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8910 N KELLOGG ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-3002
Mailing Address - Country:US
Mailing Address - Phone:503-286-4492
Mailing Address - Fax:503-765-1343
Practice Address - Street 1:8910 N KELLOGG ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-3002
Practice Address - Country:US
Practice Address - Phone:503-286-4492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD88361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice