Healthcare Provider Details

I. General information

NPI: 1447688551
Provider Name (Legal Business Name): DAVID R. TELLES, D.D.S., A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7677 CENTER AVE STE 206
HUNTINGTON BEACH CA
92647-9102
US

IV. Provider business mailing address

7677 CENTER AVE STE 206
HUNTINGTON BEACH CA
92647-9102
US

V. Phone/Fax

Practice location:
  • Phone: 714-766-6560
  • Fax: 714-766-6563
Mailing address:
  • Phone: 714-766-6560
  • Fax: 714-766-6563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number55094
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID RODNEY TELLES
Title or Position: PRESIDENT / OMFS
Credential: D.D.S.
Phone: 714-766-6560