Provider Demographics
NPI:1093392383
Name:TYLER, JILLIAN NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:NICOLE
Last Name:TYLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2277 UNION AVE APT 711
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-4331
Mailing Address - Country:US
Mailing Address - Phone:501-984-3299
Mailing Address - Fax:
Practice Address - Street 1:4201 RUCKER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2215
Practice Address - Country:US
Practice Address - Phone:425-382-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61297933122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist