Provider Demographics
NPI:1699343244
Name:CRISTOBAL, MELANIE NICOLE (DMD)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:NICOLE
Last Name:CRISTOBAL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412-22 FAIRMOUNT AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2908
Mailing Address - Country:US
Mailing Address - Phone:215-684-5344
Mailing Address - Fax:215-232-4093
Practice Address - Street 1:401-55 W ALLEGHENY AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133
Practice Address - Country:US
Practice Address - Phone:215-291-2500
Practice Address - Fax:215-291-2587
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS043634122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist