Provider Demographics
NPI:1063684827
Name:TELLEZ, BERNARD RAYMOND (DDS)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:RAYMOND
Last Name:TELLEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:BERNARD
Other - Middle Name:RAYMOND
Other - Last Name:TELLEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:5349 N 22ND ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-6645
Mailing Address - Country:US
Mailing Address - Phone:417-581-0000
Mailing Address - Fax:417-725-1564
Practice Address - Street 1:5349 N 22ND ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-6645
Practice Address - Country:US
Practice Address - Phone:417-581-0000
Practice Address - Fax:417-725-1564
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO11373122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist