MEDICARE: MISUN TISA KANG TELLEZ DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN22891	FL

General Provider Information

NPI Number	:	1992246847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISUN TISA KANG TELLEZ DMD

Provider Business Mailing Address
First Line	:	3185 CITRUS TOWER BLVD
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-6803
Country	:	US
Telephone Number	:	352-241-8471
Fax Number	:

Provider Business Practice Location Address
First Line	:	3185 CITRUS TOWER BLVD
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-6803
Country	:	US
Telephone Number	:	352-241-8471
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2017
Last Update Date	:	01/23/2026

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