Provider Demographics
NPI:1750952636
Name:VANDENBERG, MELANIE ROSE (DMD)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:ROSE
Last Name:VANDENBERG
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 1:203 VISTA BELLA DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1943
Mailing Address - Country:US
Mailing Address - Phone:831-334-3611
Mailing Address - Fax:
Practice Address - Street 1:203 VISTA BELLA DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1943
Practice Address - Country:US
Practice Address - Phone:831-334-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1063381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice