Provider Demographics
NPI:1760757116
Name:SIM, MELANIE (BS, RDH)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:
Last Name:SIM
Suffix:
Gender:F
Credentials:BS, RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2279 MOUNT VERNON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1007
Mailing Address - Country:US
Mailing Address - Phone:860-426-0467
Mailing Address - Fax:
Practice Address - Street 1:2279 MOUNT VERNON RD
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1007
Practice Address - Country:US
Practice Address - Phone:860-426-0467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004565124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist