Provider Demographics
NPI:1790765659
Name:HEATHCOTE, MELINDA A (RDH)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:A
Last Name:HEATHCOTE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 MILLS ST
Mailing Address - Street 2:
Mailing Address - City:BLACK EARTH
Mailing Address - State:WI
Mailing Address - Zip Code:53515-9420
Mailing Address - Country:US
Mailing Address - Phone:608-767-3604
Mailing Address - Fax:608-767-3606
Practice Address - Street 1:1209 MILLS ST
Practice Address - Street 2:
Practice Address - City:BLACK EARTH
Practice Address - State:WI
Practice Address - Zip Code:53515-9420
Practice Address - Country:US
Practice Address - Phone:608-767-3604
Practice Address - Fax:608-767-3606
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3712-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist