Provider Demographics
NPI:1447298898
Name:ISLAMBASIC, MELITA (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:MELITA
Middle Name:
Last Name:ISLAMBASIC
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 KNIGHTS RUN AVE
Mailing Address - Street 2:APT 2112
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 KNIGHTS RUN AVE
Practice Address - Street 2:APT 2112
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-5938
Practice Address - Country:US
Practice Address - Phone:239-989-4269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL180581223E0200X
NC150897390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223E0200XDental ProvidersDentistEndodontics