Provider Demographics
NPI:1861461683
Name:MELKONIAN, MARK J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:MELKONIAN
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 1:162 PROSPECT HILL RD
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-2331
Mailing Address - Country:US
Mailing Address - Phone:845-279-1449
Mailing Address - Fax:845-279-7790
Practice Address - Street 1:162 PROSPECT HILL RD
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-2331
Practice Address - Country:US
Practice Address - Phone:845-279-1449
Practice Address - Fax:845-279-7790
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04978611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice