Healthcare Provider Details

I. General information

NPI: 1326450867
Provider Name (Legal Business Name): SHANE ALAN FULLER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8788 JAMACHA RD
SPRING VALLEY CA
91977-4035
US

IV. Provider business mailing address

71600 GARDESS RD
RANCHO MIRAGE CA
92270-4225
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number63426
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: