Provider Demographics
NPI:1255485538
Name:MELANSON, JOHN RICHARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:MELANSON
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 1:22 PINE ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-6948
Mailing Address - Country:US
Mailing Address - Phone:860-314-0519
Mailing Address - Fax:860-314-0584
Practice Address - Street 1:22 PINE ST
Practice Address - Street 2:SUITE 208
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-6948
Practice Address - Country:US
Practice Address - Phone:860-314-0589
Practice Address - Fax:860-314-0584
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0075191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice