Provider Demographics
NPI:1942576426
Name:WATERS, MELANIE (RDHAP)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 PALM ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3113
Mailing Address - Country:US
Mailing Address - Phone:805-549-7873
Mailing Address - Fax:
Practice Address - Street 1:1177 PALM ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3113
Practice Address - Country:US
Practice Address - Phone:805-549-7873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA400124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist