Healthcare Provider Details

I. General information

NPI: 1497276729
Provider Name (Legal Business Name): FAMILY & RESTORATIVE DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7137 236TH AVE STE 108
SALEM WI
53168-8975
US

IV. Provider business mailing address

7137 236TH AVE STE 108
SALEM WI
53168-8975
US

V. Phone/Fax

Practice location:
  • Phone: 262-843-4643
  • Fax:
Mailing address:
  • Phone: 262-843-4643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number3667
License Number StateWI

VIII. Authorized Official

Name: DR. JAMES C FULMER
Title or Position: DENTIST
Credential: DDS
Phone: 262-945-2084