Healthcare Provider Details

I. General information

NPI: 1376095885
Provider Name (Legal Business Name): ANNA T. FULLER, DMD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 PELHAM DR
COLUMBIA SC
29209-1321
US

IV. Provider business mailing address

145 PELHAM DR
COLUMBIA SC
29209-1321
US

V. Phone/Fax

Practice location:
  • Phone: 803-602-3862
  • Fax:
Mailing address:
  • Phone: 803-602-3862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ANNA T FULLER
Title or Position: MEMBER
Credential: DMD
Phone: 803-528-8351