Provider Demographics
NPI:1376647818
Name:PETERSON, MELANIE R (DMD)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 W. MICHIGAN STREET
Mailing Address - Street 2:DS 307B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5186
Mailing Address - Country:US
Mailing Address - Phone:317-278-3632
Mailing Address - Fax:317-274-2603
Practice Address - Street 1:1001 W. 10TH STREET
Practice Address - Street 2:#3101
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2859
Practice Address - Country:US
Practice Address - Phone:317-278-3632
Practice Address - Fax:317-274-2603
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51041223G0001X
IN12011735A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100001450AMedicaid
KY60051042Medicaid
KY0007279OtherDORAL