Provider Demographics
NPI:1710356456
Name:DALLAS, TELSMA (MT)
Entity Type:Individual
Prefix:
First Name:TELSMA
Middle Name:
Last Name:DALLAS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:TESSIE
Other - Middle Name:
Other - Last Name:DALLAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MT
Mailing Address - Street 1:4808 MATTINGLY CT
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-3413
Mailing Address - Country:US
Mailing Address - Phone:864-978-5050
Mailing Address - Fax:
Practice Address - Street 1:4808 MATTINGLY CT
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-3413
Practice Address - Country:US
Practice Address - Phone:864-978-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMT 179117246QM0706X
NCHEW 44060069246QM0706X
LA201342.GEN246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist