Provider Demographics
NPI:1447624473
Name:MELBERG, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MELBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D DENBN/NDC, PSC 20130 315 MCHUGH BLVD
Mailing Address - Street 2:COMMANDING OFFICER
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0130
Mailing Address - Country:US
Mailing Address - Phone:910-451-2208
Mailing Address - Fax:910-451-8036
Practice Address - Street 1:11065 PACIFIC CREST PL NW STE B105
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-6607
Practice Address - Country:US
Practice Address - Phone:360-261-6154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-13
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012430A122300000X
WADE608131421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice