Provider Demographics
NPI:1225036965
Name:MELBY, WILLIAM JP (DMD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JP
Last Name:MELBY
Suffix:
Gender:M
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:PO BOX 948
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-0948
Mailing Address - Country:US
Mailing Address - Phone:503-829-7567
Mailing Address - Fax:503-829-3398
Practice Address - Street 1:128 ROSS ST
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038-9390
Practice Address - Country:US
Practice Address - Phone:503-829-7567
Practice Address - Fax:503-829-3398
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR58961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR082581Medicaid