Healthcare Provider Details

I. General information

NPI: 1669869087
Provider Name (Legal Business Name): MICHAEL T. FULBRIGHT DDS A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 VIA EL PRADO #200
REDONDO BEACH CA
90277-5722
US

IV. Provider business mailing address

1815 VIA EL PRADO #200
REDONDO BEACH CA
90277-5722
US

V. Phone/Fax

Practice location:
  • Phone: 310-316-4477
  • Fax:
Mailing address:
  • Phone: 310-316-4477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number47892
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL FULBRIGHT
Title or Position: PRESIDENT/OWNER
Credential: DDS
Phone: 310-316-4477