Healthcare Provider Details

I. General information

NPI: 1508366014
Provider Name (Legal Business Name): TYLER HAEFFS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 07/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST RM 119G
CHICAGO IL
60612
US

IV. Provider business mailing address

901 S ASHLAND AVE APT 502
CHICAGO IL
60607-4085
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-1052
  • Fax:
Mailing address:
  • Phone: 770-595-9506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019031711
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: