Healthcare Provider Details

I. General information

NPI: 1245737568
Provider Name (Legal Business Name): TRIAD OCULAR AND FACIAL PLASTIC SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6318 JESSIE LN
CLEMMONS NC
27012-9887
US

IV. Provider business mailing address

5335 ROBINHOOD VILLAGE DR # 178
WINSTON SALEM NC
27106-9820
US

V. Phone/Fax

Practice location:
  • Phone: 336-448-3060
  • Fax: 336-565-2400
Mailing address:
  • Phone: 336-448-3060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number2015-01115
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number2015-01115
License Number StateNC

VIII. Authorized Official

Name: MOLLY LYNN FULLER
Title or Position: OWNER
Credential: MD, PHD
Phone: 336-448-3060