Provider Demographics
NPI:1154862100
Name:TELISMA, VICTORIA LESLIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:LESLIE
Last Name:TELISMA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:986 MIDDLE BAY DR
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-5042
Mailing Address - Country:US
Mailing Address - Phone:516-771-1884
Mailing Address - Fax:
Practice Address - Street 1:1013 BEACH 20TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3925
Practice Address - Country:US
Practice Address - Phone:718-327-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2019-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY060184122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program