Provider Demographics
NPI:1477833440
Name:MELLOR, CHRISTY NICOLE POGUE (DDS)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:NICOLE POGUE
Last Name:MELLOR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:CHRISTY
Other - Middle Name:NICOLE
Other - Last Name:POGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:4301 DONIPHAN DR
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-9120
Mailing Address - Country:US
Mailing Address - Phone:417-451-9450
Mailing Address - Fax:417-451-8903
Practice Address - Street 1:530 S MAIDEN LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-3084
Practice Address - Country:US
Practice Address - Phone:417-782-0080
Practice Address - Fax:417-782-0096
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011023153122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist