Provider Demographics
NPI:1073205118
Name:MELGAREJO, IVETH MAGALY (DDS)
Entity Type:Individual
Prefix:DR
First Name:IVETH
Middle Name:MAGALY
Last Name:MELGAREJO
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 1:452 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-3403
Mailing Address - Country:US
Mailing Address - Phone:512-762-0381
Mailing Address - Fax:
Practice Address - Street 1:105 HIGHLAND AVE STE 2
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-3266
Practice Address - Country:US
Practice Address - Phone:269-964-3957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016017551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice