Healthcare Provider Details

I. General information

NPI: 1154549988
Provider Name (Legal Business Name): NORMAN DARTT FULLER III D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 06/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 LUNDY AVE STE 150
SAN JOSE CA
95131-1858
US

IV. Provider business mailing address

1701 LUNDY AVE STE 150
SAN JOSE CA
95131-1858
US

V. Phone/Fax

Practice location:
  • Phone: 408-437-8999
  • Fax: 408-437-8898
Mailing address:
  • Phone: 408-437-8999
  • Fax: 408-437-8898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number38285
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: