Provider Demographics
NPI:1114316171
Name:SALAZAR, MELISSA MONSERRAT (D)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MONSERRAT
Last Name:SALAZAR
Suffix:
Gender:F
Credentials:D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6283 AVENIDA DE LAS VISTAS UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-6617
Mailing Address - Country:US
Mailing Address - Phone:619-454-8415
Mailing Address - Fax:
Practice Address - Street 1:CALLE GRANADOS ESQUINA AZUZENA NUM 202
Practice Address - Street 2:
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22200
Practice Address - Country:MX
Practice Address - Phone:664-901-6184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ72779531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice