Provider Demographics
NPI:1407933740
Name:MELE, REBECCA DIANE (DDS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:DIANE
Last Name:MELE
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 1:1 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02779-1621
Mailing Address - Country:US
Mailing Address - Phone:303-619-2482
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5596
Practice Address - Country:US
Practice Address - Phone:774-826-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9115122300000X
RIDEN03005122300000X
MADN1855519122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79682057Medicaid