Provider Demographics
NPI:1770063273
Name:VARUGHESE, MELVIN (DMD)
Entity type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:
Last Name:VARUGHESE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3709
Mailing Address - Country:US
Mailing Address - Phone:715-392-1955
Mailing Address - Fax:715-392-1935
Practice Address - Street 1:2222 E 5TH ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-3709
Practice Address - Country:US
Practice Address - Phone:715-392-1955
Practice Address - Fax:715-392-1935
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10024811223G0001X, 1223G0001X
TX344001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXFV7790579OtherDEPARTMENT OF JUSTICE DEA
TX34400OtherTEXAS STATE BOARD OF DENTAL EXAMINERS