Provider Demographics
NPI:1356406342
Name:BLOCK, MELANIE J (LD)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:J
Last Name:BLOCK
Suffix:
Gender:
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NE 20TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3094
Mailing Address - Country:US
Mailing Address - Phone:503-230-0207
Mailing Address - Fax:503-230-0208
Practice Address - Street 1:1584 NE 8TH ST STE 208
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5746
Practice Address - Country:US
Practice Address - Phone:503-230-0207
Practice Address - Fax:503-230-0208
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDTDO317601122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269892Medicaid