Provider Demographics
NPI:1578585451
Name:MARK D. MELLMAN, DDS. PA
Entity Type:Organization
Organization Name:MARK D. MELLMAN, DDS. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:813-654-4545
Mailing Address - Street 1:721 W ROBERTSON ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4934
Mailing Address - Country:US
Mailing Address - Phone:813-654-4545
Mailing Address - Fax:813-654-3470
Practice Address - Street 1:721 W ROBERTSON ST
Practice Address - Street 2:SUITE 107
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4934
Practice Address - Country:US
Practice Address - Phone:813-654-4545
Practice Address - Fax:813-654-3470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8712261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental