Provider Demographics
NPI:1609457316
Name:MELLO, HILARY JACKSON
Entity Type:Individual
Prefix:
First Name:HILARY
Middle Name:JACKSON
Last Name:MELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 HELEN ST
Mailing Address - Street 2:
Mailing Address - City:ACUSHNET
Mailing Address - State:MA
Mailing Address - Zip Code:02743-1319
Mailing Address - Country:US
Mailing Address - Phone:508-717-1008
Mailing Address - Fax:
Practice Address - Street 1:802 CONSTITUTION AVE
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:MA
Practice Address - Zip Code:01460-1137
Practice Address - Country:US
Practice Address - Phone:508-717-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN18593371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program