Provider Demographics
NPI:1124224308
Name:TELLEZ, HEATHER MAE (DDS)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:MAE
Last Name:TELLEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 NEALY BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:72 NEALY AVE
Practice Address - Street 2:
Practice Address - City:LANGLEY AFB
Practice Address - State:VA
Practice Address - Zip Code:23665-5300
Practice Address - Country:US
Practice Address - Phone:907-580-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPENDING1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice