=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245764331
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMMY CARVLIN TELLEZ R.D.H., O.M.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2017
-----------------------------------------------------
Last Update Date | 04/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4464 VISTA DE LUZ CT
-----------------------------------------------------
City | LAS CRUCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88011-0917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-621-3643
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4464 VISTA DE LUZ CT
-----------------------------------------------------
City | LAS CRUCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88011-0917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-621-3643
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | DH2738
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------