Active NPI
Melanie R Peterson, DMD
- Oral and Maxillofacial Surgery (Dentist)
- Indianapolis, IN
National Provider Identifier
1376647818
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Oral and Maxillofacial Surgery (Dentist)
- License
- 12011735A
- Practice address
- 1001 W. 10TH Street
#3101
Indianapolis, IN 46202-2859 - Phone
- (317) 278-3632
- Fax
- (317) 274-2603
- NPI assigned
- Sep 12, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 5104 | KY | |
| Oral and Maxillofacial Surgery (Dentist) | 1223S0112X | 12011735A | IN | Primary |
Addresses
Primary practice location
1001 W. 10TH Street
#3101
Indianapolis, IN 46202-2859
Mailing address
1121 W. Michigan Street
DS 307B
Indianapolis, IN 46202-5186
Phone (317) 278-3632
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100001450A | Medicaid | IN | |
| 60051042 | Medicaid | KY | |
| 0007279 | Other | KY | DORAL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5104 | KY | MD | Clinical Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1158019200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1340064000000",
"number": "1376647818",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1121 W. MICHIGAN STREET",
"address_2": "DS 307B",
"city": "INDIANAPOLIS",
"state": "IN",
"postal_code": "462025186",
"telephone_number": "317-278-3632",
"fax_number": "317-274-2603"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1001 W. 10TH STREET",
"address_2": "#3101",
"city": "INDIANAPOLIS",
"state": "IN",
"postal_code": "462022859",
"telephone_number": "317-278-3632",
"fax_number": "317-274-2603"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSON",
"first_name": "MELANIE",
"middle_name": "R",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-09-12",
"last_updated": "2012-06-19",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "KY",
"license": "5104",
"primary": false
},
{
"code": "1223S0112X",
"taxonomy_group": "",
"desc": "Dentist, Oral and Maxillofacial Surgery",
"state": "IN",
"license": "12011735A",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "100001450A",
"state": "IN"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "60051042",
"state": "KY"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DORAL",
"identifier": "0007279",
"state": "KY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Indianapolis, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 19, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.