Provider Demographics
NPI:1689262081
Name:PETERSON, MELISSA (RDH, PHDHP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RDH, PHDHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 DWIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:KANE
Mailing Address - State:PA
Mailing Address - Zip Code:16735-3713
Mailing Address - Country:US
Mailing Address - Phone:814-366-3867
Mailing Address - Fax:
Practice Address - Street 1:263 DWIGHTS RD
Practice Address - Street 2:
Practice Address - City:KANE
Practice Address - State:PA
Practice Address - Zip Code:16735-3713
Practice Address - Country:US
Practice Address - Phone:814-366-3867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-02
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH011007L124Q00000X
PAPHDH000238124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist