Healthcare Provider Details

I. General information

NPI: 1366936783
Provider Name (Legal Business Name): PEAK DENTAL IMPLANT SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 ELM ST
AMESBURY MA
01913-4320
US

IV. Provider business mailing address

41 SPARHAWK ST
AMESBURY MA
01913-3317
US

V. Phone/Fax

Practice location:
  • Phone: 978-388-3505
  • Fax: 978-388-6363
Mailing address:
  • Phone: 978-388-3505
  • Fax:

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 Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN21905
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. BRAD LYLE FULKERSON
Title or Position: DENTIST / OWNER
Credential: DMD
Phone: 978-388-3505