Provider Demographics
NPI:1790840106
Name:MELSON, MARK W (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:MELSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10016 E 67TH ST
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-5219
Mailing Address - Country:US
Mailing Address - Phone:816-737-3400
Mailing Address - Fax:
Practice Address - Street 1:10016 E 67TH ST
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-5219
Practice Address - Country:US
Practice Address - Phone:816-737-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO013695122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1B0J4COtherDENTE-MAX ID NUMBER
MO18507068OtherBLUE CROSS BLUE SHIELD ID