Provider Demographics
NPI:1689753626
Name:MELLIS, ROBERT PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:PAUL
Last Name:MELLIS
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 1:5125 OLEANDER
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403
Mailing Address - Country:US
Mailing Address - Phone:910-392-2920
Mailing Address - Fax:910-392-2221
Practice Address - Street 1:5125 OLEANDER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-7065
Practice Address - Country:US
Practice Address - Phone:910-392-2920
Practice Address - Fax:910-392-2221
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7011122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899012HMedicaid
001524490OtherUNITED CONCORDIA