Provider Demographics
NPI:1700213188
Name:MELLMAN, MARK DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:MELLMAN
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 1:721 W. ROBERTSON ST.
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511
Mailing Address - Country:US
Mailing Address - Phone:813-654-4545
Mailing Address - Fax:813-654-3470
Practice Address - Street 1:721 W. ROBERTSON ST.
Practice Address - Street 2:SUITE 107
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511
Practice Address - Country:US
Practice Address - Phone:813-654-4545
Practice Address - Fax:813-654-3470
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN8712122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist