Provider Demographics
NPI:1568742476
Name:DIAMOND, MELODIE R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELODIE
Middle Name:R
Last Name:DIAMOND
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 HARRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-1962
Mailing Address - Country:US
Mailing Address - Phone:214-218-7403
Mailing Address - Fax:
Practice Address - Street 1:2815 HARRIS BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-1962
Practice Address - Country:US
Practice Address - Phone:214-218-7403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011015044122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist