Provider Demographics
NPI:1487216495
Name:TELLO, COURTNI NICOLE (DDS)
Entity Type:Individual
Prefix:
First Name:COURTNI
Middle Name:NICOLE
Last Name:TELLO
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 1:616 WHITE IBIS AVE
Mailing Address - Street 2:
Mailing Address - City:TEXAS CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77590-4242
Mailing Address - Country:US
Mailing Address - Phone:409-256-4896
Mailing Address - Fax:
Practice Address - Street 1:1130 14TH ST N
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77590-5413
Practice Address - Country:US
Practice Address - Phone:409-256-4896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice