Provider Demographics
NPI:1699294439
Name:TELLES, JAMIE LEAH (RDA)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEAH
Last Name:TELLES
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3027 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545
Mailing Address - Country:US
Mailing Address - Phone:951-791-9111
Mailing Address - Fax:
Practice Address - Street 1:3027 W FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-3617
Practice Address - Country:US
Practice Address - Phone:951-791-9111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA81056126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDA81056OtherDENTAL BOARD OF CALIFORNIA