Provider Demographics
NPI:1629190640
Name:TELLOIAN, JAMES E (DDS)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:TELLOIAN
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 1:1930 BLACK LAKE BLVD SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98512-5651
Mailing Address - Country:US
Mailing Address - Phone:360-352-0847
Mailing Address - Fax:360-352-2029
Practice Address - Street 1:1930 BLACK LAKE BLVD SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98512-5651
Practice Address - Country:US
Practice Address - Phone:360-352-0847
Practice Address - Fax:360-352-2029
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000064421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADE00006442OtherWA STATE LICENSE