Provider Demographics
NPI:1679627590
Name:CARLOS G. TELLO DDS MS PA
Entity Type:Organization
Organization Name:CARLOS G. TELLO DDS MS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:G
Authorized Official - Last Name:TELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:817-281-9141
Mailing Address - Street 1:5340 DAVIS BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76180
Mailing Address - Country:US
Mailing Address - Phone:817-281-9141
Mailing Address - Fax:
Practice Address - Street 1:5340 DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76180
Practice Address - Country:US
Practice Address - Phone:817-281-9141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX193051223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty