Provider Demographics
NPI:1427611755
Name:FULLEN, KATLYN ELIZABETH (DDS)
Entity type:Individual
Prefix:DR
First Name:KATLYN
Middle Name:ELIZABETH
Last Name:FULLEN
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 1:150 STUART XING NE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-4065
Mailing Address - Country:US
Mailing Address - Phone:423-476-2160
Mailing Address - Fax:
Practice Address - Street 1:150 STUART XING NE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4065
Practice Address - Country:US
Practice Address - Phone:423-472-9930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN115541223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program