Provider Demographics
NPI:1972032324
Name:VARELA KELLESARIAN, SERGIO MANUEL (DDS)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:MANUEL
Last Name:VARELA KELLESARIAN
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 1:12634 PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1712
Mailing Address - Country:US
Mailing Address - Phone:954-430-2300
Mailing Address - Fax:
Practice Address - Street 1:12634 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1712
Practice Address - Country:US
Practice Address - Phone:954-430-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN24657122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program