Provider Demographics
NPI:1679601959
Name:MELANCON, TIM A (DDS)
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:A
Last Name:MELANCON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3414 HESSMER AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-4759
Mailing Address - Country:US
Mailing Address - Phone:504-889-1165
Mailing Address - Fax:504-889-1177
Practice Address - Street 1:3414 HESSMER AVE
Practice Address - Street 2:STE 201
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-4759
Practice Address - Country:US
Practice Address - Phone:504-889-1165
Practice Address - Fax:504-889-1177
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA50461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice