Provider Demographics
NPI:1063759736
Name:MELANCON FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:MELANCON FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MELANCON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:337-837-1861
Mailing Address - Street 1:300 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-4518
Mailing Address - Country:US
Mailing Address - Phone:337-837-1861
Mailing Address - Fax:337-837-1278
Practice Address - Street 1:300 W MADISON ST
Practice Address - Street 2:
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518-4518
Practice Address - Country:US
Practice Address - Phone:337-837-1861
Practice Address - Fax:337-837-1278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5974261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental