Provider Demographics
NPI:1508602368
Name:DEMATTEIS, MELODY A
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:A
Last Name:DEMATTEIS
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 1:40 W WELLSBORO ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16933-1411
Mailing Address - Country:US
Mailing Address - Phone:570-662-1945
Mailing Address - Fax:
Practice Address - Street 1:116 SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:BLOSSBURG
Practice Address - State:PA
Practice Address - Zip Code:16912-1418
Practice Address - Country:US
Practice Address - Phone:570-638-2174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0446741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice