Provider Demographics
NPI:1700598695
Name:METELKO, MISTY LEE (RDH)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:LEE
Last Name:METELKO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 N 100 E
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-2408
Mailing Address - Country:US
Mailing Address - Phone:435-851-2855
Mailing Address - Fax:
Practice Address - Street 1:331 E HIGHWAY 123
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:UT
Practice Address - Zip Code:84539-7725
Practice Address - Country:US
Practice Address - Phone:435-888-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7359220-9920124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist