Healthcare Provider Details

I. General information

NPI: 1225342314
Provider Name (Legal Business Name): RAELENE FRANCES FULFORD DDS, MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RAELENE FRANCES MCDOWALL DDS

II. Dates (important events)

Enumeration Date: 07/30/2010
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W 72ND AVE
DENVER CO
80221-2721
US

IV. Provider business mailing address

1345 PLAZA CT N 1A
LAFAYETTE CO
80026-3531
US

V. Phone/Fax

Practice location:
  • Phone: 303-650-4460
  • Fax: 720-206-0434
Mailing address:
  • Phone: 303-665-3036
  • Fax: 720-206-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number56263
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00202002
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: