Provider Demographics
NPI:1366750986
Name:DOUGLASS, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:DOUGLASS
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 1:58 BUTTER ST
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04443-6039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:58 BUTTER ST
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:ME
Practice Address - Zip Code:04443-6039
Practice Address - Country:US
Practice Address - Phone:207-717-7084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2203124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist