Provider Demographics
NPI:1336852144
Name:MELLON DENTAL MANAGEMENT, PLLC
Entity Type:Organization
Organization Name:MELLON DENTAL MANAGEMENT, PLLC
Other - Org Name:TOOTH SCOOTIN' BOOGIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:MELLON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:830-796-3548
Mailing Address - Street 1:PO BOX 3612
Mailing Address - Street 2:
Mailing Address - City:BANDERA
Mailing Address - State:TX
Mailing Address - Zip Code:78003-6611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:584 STATE HIGHWAY 16 S
Practice Address - Street 2:
Practice Address - City:BANDERA
Practice Address - State:TX
Practice Address - Zip Code:78003-3808
Practice Address - Country:US
Practice Address - Phone:830-796-3548
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-27
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty