Provider Demographics
NPI:1619631413
Name:PEDERSON, MELVIN DAVID JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:DAVID
Last Name:PEDERSON
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E MAIN ST STE 190
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4163
Mailing Address - Country:US
Mailing Address - Phone:810-287-5361
Mailing Address - Fax:
Practice Address - Street 1:15121 E MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-3746
Practice Address - Country:US
Practice Address - Phone:303-802-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00204856122300000X, 1223X0400X
ORD118681223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist