Provider Demographics
NPI:1255861449
Name:ASTORGA, MELYSSA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELYSSA
Middle Name:
Last Name:ASTORGA
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 1:393 HEWES ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-6316
Mailing Address - Country:US
Mailing Address - Phone:916-217-6985
Mailing Address - Fax:
Practice Address - Street 1:11 BROADWAY LBBY 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004
Practice Address - Country:US
Practice Address - Phone:212-425-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0600001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program