Provider Demographics
NPI:1053690222
Name:DELOACH, MELANIE WOODWARD (DMD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:WOODWARD
Last Name:DELOACH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 GOLFSIDE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-367-1722
Mailing Address - Fax:
Practice Address - Street 1:9000 GOLFSIDE DR
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-367-1722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19493122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist