Provider Demographics
NPI:1740612860
Name:TRUMBO, MELISSA LIU FISH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:LIU FISH
Last Name:TRUMBO
Suffix:
Gender:F
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:BUREAU OF MEDICINE AND SURGERY, CENTRALIZED CREDENTIALS
Mailing Address - Street 2:& PRIVILEGING DIRECTORATE - 554 KEILY STREET
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212
Mailing Address - Country:US
Mailing Address - Phone:757-953-8609
Mailing Address - Fax:
Practice Address - Street 1:BUREAU OF MEDICINE AND SURGERY, CENTRALIZED CREDENTIALS
Practice Address - Street 2:& PRIVILEGING DIRECTORATE - 554 KEILY STREET
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212
Practice Address - Country:US
Practice Address - Phone:757-953-8609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013016367122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist