Provider Demographics
NPI:1609845031
Name:MELEAN, ALFONSO J (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:J
Last Name:MELEAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 E 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33605-4704
Mailing Address - Country:US
Mailing Address - Phone:813-248-8515
Mailing Address - Fax:813-241-2709
Practice Address - Street 1:4802 E 7TH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33605-4704
Practice Address - Country:US
Practice Address - Phone:813-248-8515
Practice Address - Fax:813-241-2709
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-142051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071409700Medicaid