Provider Demographics
NPI:1699184150
Name:VATHIELIL, JELENA MARY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JELENA
Middle Name:MARY
Last Name:VATHIELIL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6309 NW 74TH TER
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33067-1232
Mailing Address - Country:US
Mailing Address - Phone:954-303-7578
Mailing Address - Fax:
Practice Address - Street 1:6309 NW 74TH TER
Practice Address - Street 2:
Practice Address - City:PARKLAND
Practice Address - State:FL
Practice Address - Zip Code:33067-1232
Practice Address - Country:US
Practice Address - Phone:954-303-7578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-10
Last Update Date:2014-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 208541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice