Provider Demographics
NPI:1285476366
Name:MELLIN, MATTHEW DAVIS (DMD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVIS
Last Name:MELLIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HUMPHREY CT UNIT A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5301
Mailing Address - Country:US
Mailing Address - Phone:843-714-3283
Mailing Address - Fax:
Practice Address - Street 1:1122 PROFESSIONAL LN
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7193
Practice Address - Country:US
Practice Address - Phone:843-972-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.108161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice