Provider Demographics
NPI:1417333972
Name:MELLOR, MATTHEW (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MELLOR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 HAWKESBURY TER
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-6311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:WA
Practice Address - Zip Code:99111-1801
Practice Address - Country:US
Practice Address - Phone:509-397-4077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 605734381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice