Provider Demographics
NPI:1417099698
Name:MELDE, MICHAEL J (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MELDE
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 1:2156 MCCULLOCH BLVD
Mailing Address - Street 2:#6
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403
Mailing Address - Country:US
Mailing Address - Phone:928-854-5551
Mailing Address - Fax:928-854-5628
Practice Address - Street 1:2156 MCCULLOCH BLVD
Practice Address - Street 2:#6
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-854-5551
Practice Address - Fax:928-854-5628
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33451223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ091885OtherAHCCCS