Provider Demographics
NPI:1598842270
Name:FELLNER, THOMAS A (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:FELLNER
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 1:5471 SCOTT VIEW LANE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813
Mailing Address - Country:US
Mailing Address - Phone:863-646-2966
Mailing Address - Fax:
Practice Address - Street 1:715 S BROADWAY
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830
Practice Address - Country:US
Practice Address - Phone:863-533-2185
Practice Address - Fax:863-533-8463
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6787122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist