Provider Demographics
NPI:1164500377
Name:RICHARDSON, MELODY MILLER (DDS)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:MILLER
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MELODY
Other - Middle Name:MILLER
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS PC
Mailing Address - Street 1:63 WEST SIXTH ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-2134
Mailing Address - Country:US
Mailing Address - Phone:765-473-4109
Mailing Address - Fax:
Practice Address - Street 1:63 WEST 6TH ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-2134
Practice Address - Country:US
Practice Address - Phone:765-473-4109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2021-10-22
Deactivation Date:2021-10-22
Deactivation Code:
Reactivation Date:2021-10-22
Provider Licenses
StateLicense IDTaxonomies
IN12009144A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist