Provider Demographics
NPI:1760500946
Name:MELENDEZ, KIMBERLY (DDS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MELENDEZ
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 1:813 MEADOW CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3524
Mailing Address - Country:US
Mailing Address - Phone:903-581-6003
Mailing Address - Fax:
Practice Address - Street 1:824 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2016
Practice Address - Country:US
Practice Address - Phone:903-597-0460
Practice Address - Fax:903-597-0539
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX169791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice