Healthcare Provider Details

I. General information

NPI: 1891899811
Provider Name (Legal Business Name): CHAD COLEMAN FULMER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 SERAPH DR SUITE 4
CONWAY AR
72034-3361
US

IV. Provider business mailing address

4055 SERAPH DR SUITE 4
CONWAY AR
72034-3361
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-7668
  • Fax: 501-329-2077
Mailing address:
  • Phone: 501-329-7668
  • Fax: 501-329-2077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3334
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: