Provider Demographics
NPI:1548788516
Name:TANDOC, MIA MELANIE AMBROCIO (RDH)
Entity Type:Individual
Prefix:
First Name:MIA MELANIE
Middle Name:AMBROCIO
Last Name:TANDOC
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 1:1351 KENAI AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99505-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 N MULDOON RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-6104
Practice Address - Country:US
Practice Address - Phone:907-257-4940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9545124Q00000X
AK134230124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist