Provider Demographics
NPI:1093936767
Name:TELICH, MARTIN H (DDS)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:H
Last Name:TELICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5433 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:VERMILION
Mailing Address - State:OH
Mailing Address - Zip Code:44089-1333
Mailing Address - Country:US
Mailing Address - Phone:440-967-5277
Mailing Address - Fax:
Practice Address - Street 1:5433 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:VERMILION
Practice Address - State:OH
Practice Address - Zip Code:44089-1333
Practice Address - Country:US
Practice Address - Phone:440-967-5277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH182931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice