Provider Demographics
NPI:1912647801
Name:TEAGUE, MELINDA JANE
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:JANE
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 CUMBERLAND LN STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-2702
Mailing Address - Country:US
Mailing Address - Phone:423-562-9459
Mailing Address - Fax:
Practice Address - Street 1:116 CUMBERLAND LN STE 1
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-2702
Practice Address - Country:US
Practice Address - Phone:423-562-9459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDH0000002784124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist