Provider Demographics
NPI:1407062128
Name:MICHAEL D. MELLUM, DMD PC
Entity Type:Organization
Organization Name:MICHAEL D. MELLUM, DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DEANE
Authorized Official - Last Name:MELLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-286-4492
Mailing Address - Street 1:8910 N KELLOGG ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-3002
Mailing Address - Country:US
Mailing Address - Phone:503-286-4492
Mailing Address - Fax:
Practice Address - Street 1:8910 N KELLOGG ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-3002
Practice Address - Country:US
Practice Address - Phone:503-286-4492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty