Provider Demographics
NPI:1255643391
Name:BLANK, MELISSA J (DDS)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:J
Last Name:BLANK
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 1:907 11TH ST
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742-1207
Mailing Address - Country:US
Mailing Address - Phone:563-659-3411
Mailing Address - Fax:563-659-2831
Practice Address - Street 1:907 11TH ST
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:IA
Practice Address - Zip Code:52742-1207
Practice Address - Country:US
Practice Address - Phone:563-659-3411
Practice Address - Fax:563-659-2831
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08740122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist