Healthcare Provider Details

I. General information

NPI: 1225185515
Provider Name (Legal Business Name): BRADLEY TODD FULKERSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700A BARRETT BLVD
HENDERSON KY
42420-4931
US

IV. Provider business mailing address

700A BARRETT BLVD P.O. BOX 276
HENDERSON KY
42420-4931
US

V. Phone/Fax

Practice location:
  • Phone: 270-827-5522
  • Fax: 270-827-8272
Mailing address:
  • Phone: 270-827-5522
  • Fax: 270-827-8272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7040
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7040
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12009862A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: