Provider Demographics
NPI:1124114103
Name:TELLATIN, GREGORY CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CHARLES
Last Name:TELLATIN
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 1:1628 S. CAMPBELL
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807
Mailing Address - Country:US
Mailing Address - Phone:417-862-0782
Mailing Address - Fax:417-862-3866
Practice Address - Street 1:1628 S. CAMPBELL
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-2002
Practice Address - Country:US
Practice Address - Phone:417-862-0782
Practice Address - Fax:417-862-3866
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO141751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice