Healthcare Provider Details

I. General information

NPI: 1417152190
Provider Name (Legal Business Name): ANNA TYSON FULLER D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 04/22/2023
Certification Date: 04/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 GARNERS FERRY RD STE X
COLUMBIA SC
29209-1632
US

IV. Provider business mailing address

6420 GARNERS FERRY RD STE X
COLUMBIA SC
29209-1632
US

V. Phone/Fax

Practice location:
  • Phone: 803-528-8351
  • Fax:
Mailing address:
  • Phone: 803-661-8412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4334
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: