Provider Demographics
NPI:1194361261
Name:MELTON, SUSAN LEAH (RDH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEAH
Last Name:MELTON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 CUSTIS LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-3773
Mailing Address - Country:US
Mailing Address - Phone:865-789-2081
Mailing Address - Fax:
Practice Address - Street 1:811 HIGH ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5030
Practice Address - Country:US
Practice Address - Phone:865-982-2421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDH2761124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDH2761OtherDENTAL HYGIENE LICENSE