Provider Demographics
NPI:1386635514
Name:LACKEY, MELISSA M (DMD,MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:M
Last Name:LACKEY
Suffix:
Gender:F
Credentials:DMD,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-2711
Mailing Address - Country:US
Mailing Address - Phone:781-662-6228
Mailing Address - Fax:781-622-4455
Practice Address - Street 1:810 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-2711
Practice Address - Country:US
Practice Address - Phone:781-662-6228
Practice Address - Fax:781-622-4455
Is Sole Proprietor?:No
Enumeration Date:2005-11-05
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA194571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA16806OtherPILGRIM
MA791536OtherTUFTS
MAX08852OtherBCBS
MA16806OtherPILGRIM
MAU96186Medicare UPIN