Provider Demographics
NPI:1629642111
Name:NORDSTROM, MELISSA L (DMD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:NORDSTROM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 E CHATEAU RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-4600
Mailing Address - Country:US
Mailing Address - Phone:763-300-8526
Mailing Address - Fax:
Practice Address - Street 1:785 E 200 S STE 1
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2291
Practice Address - Country:US
Practice Address - Phone:435-215-1395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12231482-9923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist