Provider Demographics
NPI:1558711010
Name:HADERLIE, TYLEN K (DDS)
Entity type:Individual
Prefix:DR
First Name:TYLEN
Middle Name:K
Last Name:HADERLIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5315 FOUNTAIN RD STE A
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-3094
Mailing Address - Country:US
Mailing Address - Phone:865-687-6763
Mailing Address - Fax:865-688-8503
Practice Address - Street 1:5315 FOUNTAIN RD STE A
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-3094
Practice Address - Country:US
Practice Address - Phone:865-687-6763
Practice Address - Fax:865-688-8503
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016017398122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No122300000XDental ProvidersDentist