Provider Demographics
NPI:1992985030
Name:BOURDEAU, MELISSA (RDH)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:
Last Name:BOURDEAU
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 BEAVER BROOK RD
Mailing Address - Street 2:DANBURY PUBLIC SCHOOL DENTAL PROGRAM
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6211
Mailing Address - Country:US
Mailing Address - Phone:203-792-2812
Mailing Address - Fax:203-792-2612
Practice Address - Street 1:63 BEAVER BROOK RD
Practice Address - Street 2:DANBURY PUBLIC SCHOOL DENTAL PROGRAM
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6211
Practice Address - Country:US
Practice Address - Phone:203-792-2812
Practice Address - Fax:203-792-2612
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004700124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist