Provider Demographics
NPI:1639161706
Name:FEDERBUSCH, MELVIN D (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:D
Last Name:FEDERBUSCH
Suffix:
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 1:1432 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:WHITE OAK
Mailing Address - State:PA
Mailing Address - Zip Code:15131-1600
Mailing Address - Country:US
Mailing Address - Phone:412-672-9657
Mailing Address - Fax:
Practice Address - Street 1:1432 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:WHITE OAK
Practice Address - State:PA
Practice Address - Zip Code:15131-1600
Practice Address - Country:US
Practice Address - Phone:412-672-9657
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS015365L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
T82133Medicare UPIN
61603Medicare ID - Type Unspecified