Provider Demographics
NPI:1508305970
Name:DISMUKE, MELISSA
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:DISMUKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3562 THRESHFIELD ST
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695-4200
Mailing Address - Country:US
Mailing Address - Phone:951-240-8993
Mailing Address - Fax:
Practice Address - Street 1:3562 THRESHFIELD ST
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695-4200
Practice Address - Country:US
Practice Address - Phone:951-240-8993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-18
Last Update Date:2017-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor