Provider Demographics
NPI:1992246847
Name:TELLEZ, MISUN TISA KANG (DMD)
Entity type:Individual
Prefix:
First Name:MISUN
Middle Name:TISA KANG
Last Name:TELLEZ
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 1:560 FOX HUNT CIR
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-3348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 FOX HUNT CIR
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-3348
Practice Address - Country:US
Practice Address - Phone:407-463-4456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-12
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00203474122300000X
390200000X
FLDN22891122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program