Provider Demographics
NPI:1689700312
Name:MERRIAM, MELANIE (RDH)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MERRIAM
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4152 GATES RD
Mailing Address - Street 2:
Mailing Address - City:JAMESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13078-9624
Mailing Address - Country:US
Mailing Address - Phone:315-682-7881
Mailing Address - Fax:315-492-6169
Practice Address - Street 1:100 INTREPID LN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2546
Practice Address - Country:US
Practice Address - Phone:315-492-8138
Practice Address - Fax:315-492-6169
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016947-1124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016947-1OtherRDH LICENSE #