Healthcare Provider Details

I. General information

NPI: 1568247203
Provider Name (Legal Business Name): FULBRIGHT AND FAIST DENTAL PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2023
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 VIA EL PRADO, SUITE 200
REDONDO BEACH CA
90277
US

IV. Provider business mailing address

1815 VIA EL PRADO, SUITE 200
REDONDO BEACH CA
90277
US

V. Phone/Fax

Practice location:
  • Phone: 310-316-4477
  • Fax: 310-316-4475
Mailing address:
  • Phone: 310-316-4477
  • Fax: 310-316-4475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL FULBRIGHT
Title or Position: PARTNER
Credential: DDS
Phone: 310-316-4477