Provider Demographics
NPI:1386241636
Name:MELLISSA ILGEN, DDS, PLLC
Entity type:Organization
Organization Name:MELLISSA ILGEN, DDS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MELLISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ILGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-900-1417
Mailing Address - Street 1:PO BOX 149
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-0149
Mailing Address - Country:US
Mailing Address - Phone:360-297-3392
Mailing Address - Fax:
Practice Address - Street 1:26114 ILLINOIS AVE NE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-7674
Practice Address - Country:US
Practice Address - Phone:360-297-3392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental