Provider Demographics
NPI:1780711812
Name:RUKAMP, MELISSA LYNN (RDH)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:RUKAMP
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LYNN
Other - Last Name:ROTTIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:2442 FORESTVILLE DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-1710
Mailing Address - Country:US
Mailing Address - Phone:920-499-8733
Mailing Address - Fax:
Practice Address - Street 1:1711 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3215
Practice Address - Country:US
Practice Address - Phone:920-494-9541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3937-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist