Provider Demographics
NPI:1063505113
Name:PLANTATION DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:PLANTATION DENTAL ASSOCIATES
Other - Org Name:DR JACK H MELTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:HEYWARD
Authorized Official - Last Name:MELTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-638-9001
Mailing Address - Street 1:300 MAIN ST
Mailing Address - Street 2:STE 101
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-1666
Mailing Address - Country:US
Mailing Address - Phone:912-638-9001
Mailing Address - Fax:912-634-9819
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:STE 101
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-1666
Practice Address - Country:US
Practice Address - Phone:912-638-9001
Practice Address - Fax:912-634-9819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0082851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty