Provider Demographics
NPI:1922173715
Name:MAYBERRY, MELANIE ELAINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:ELAINE
Last Name:MAYBERRY
Suffix:
Gender:F
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:P.O. BOX 21-785
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221
Mailing Address - Country:US
Mailing Address - Phone:313-835-6758
Mailing Address - Fax:313-835-6759
Practice Address - Street 1:18940 SCHOOLCRAFT
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2906
Practice Address - Country:US
Practice Address - Phone:313-835-6758
Practice Address - Fax:313-835-6759
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010165441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice