Provider Demographics
NPI:1245764331
Name:CARVLIN TELLEZ, TAMMY (RDH, OM)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:CARVLIN TELLEZ
Suffix:
Gender:F
Credentials:RDH, OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4464 VISTA DE LUZ CT
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-0917
Mailing Address - Country:US
Mailing Address - Phone:575-621-3643
Mailing Address - Fax:
Practice Address - Street 1:4464 VISTA DE LUZ CT
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-0917
Practice Address - Country:US
Practice Address - Phone:575-621-3643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH2738124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist