Provider Demographics
NPI:1508159625
Name:MELLO, LISA A
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:MELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 FAUNCE CORNER RD UNIT 120
Mailing Address - Street 2:
Mailing Address - City:N DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-1262
Mailing Address - Country:US
Mailing Address - Phone:508-997-1221
Mailing Address - Fax:508-858-0622
Practice Address - Street 1:92 FAUNCE CORNER RD UNIT 120
Practice Address - Street 2:
Practice Address - City:N DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1262
Practice Address - Country:US
Practice Address - Phone:508-997-1221
Practice Address - Fax:508-858-0622
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADH10340124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADH10340OtherMASS BOARD OF DENTISTRY