Provider Demographics
NPI:1548575236
Name:COLLETT, MELISSA RAE (RDH)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:RAE
Last Name:COLLETT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55807-2730
Mailing Address - Country:US
Mailing Address - Phone:218-628-7035
Mailing Address - Fax:218-624-6594
Practice Address - Street 1:4325 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2730
Practice Address - Country:US
Practice Address - Phone:218-628-7035
Practice Address - Fax:218-624-6594
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH8731124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist