Healthcare Provider Details

I. General information

NPI: 1528128626
Provider Name (Legal Business Name): LORI FULK DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 W. LOOP 1604 N. SUITE 109
SAN ANTONIO TX
78251
US

IV. Provider business mailing address

430 W. LOOP 1604 N. SUITE 109
SAN ANTONIO TX
78251
US

V. Phone/Fax

Practice location:
  • Phone: 210-647-7447
  • Fax: 210-647-7839
Mailing address:
  • Phone: 210-647-7447
  • Fax: 210-647-7839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22556
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: