Provider Demographics
NPI:1790276319
Name:VINCENT, KATELYN MELISSA (DMD)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MELISSA
Last Name:VINCENT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 SWEDES ST
Mailing Address - Street 2:
Mailing Address - City:DEWEY BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-3316
Mailing Address - Country:US
Mailing Address - Phone:302-381-7091
Mailing Address - Fax:
Practice Address - Street 1:18912 JOHN J WILLIAMS HWY
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-4403
Practice Address - Country:US
Practice Address - Phone:302-645-6671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DEG1-0001448122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty