Provider Demographics
NPI:1801200514
Name:MELLON, RANDI (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDI
Middle Name:
Last Name:MELLON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3285 BROAD OAK DR
Mailing Address - Street 2:
Mailing Address - City:BANDERA
Mailing Address - State:TX
Mailing Address - Zip Code:78003-3784
Mailing Address - Country:US
Mailing Address - Phone:361-537-2634
Mailing Address - Fax:
Practice Address - Street 1:11010 W FM 471 STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-4991
Practice Address - Country:US
Practice Address - Phone:210-688-9386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858319122300000X
TX30105122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist