Provider Demographics
NPI:1073737573
Name:TELLIOS, TIM S (DMD PA)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:S
Last Name:TELLIOS
Suffix:
Gender:M
Credentials:DMD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4714 N ARMENIA AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2603
Mailing Address - Country:US
Mailing Address - Phone:813-876-1200
Mailing Address - Fax:813-870-2970
Practice Address - Street 1:4714 N ARMENIA AVE STE 102
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2603
Practice Address - Country:US
Practice Address - Phone:813-876-1200
Practice Address - Fax:813-870-2970
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0125621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice