Provider Demographics
NPI:1578746863
Name:CHRISTIANSON, MELINDA LOUISE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:LOUISE
Last Name:CHRISTIANSON
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 1:1526 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1852
Mailing Address - Country:US
Mailing Address - Phone:415-456-4744
Mailing Address - Fax:415-456-1069
Practice Address - Street 1:1526 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-1852
Practice Address - Country:US
Practice Address - Phone:415-456-4744
Practice Address - Fax:415-456-1069
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice