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General NPI Number Information
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NPI Number | 1154706380
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Entity Type | Individual
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Provider Name | CHARLES MICHAEL FULLEM D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/29/2015
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Last Update Date | 08/28/2023
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Provider Practice Location Address
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Address Line | 2250 MILLENNIUM WAY STE 101
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City | ENOLA
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State | PA
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Zip | 17025-1488
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Country | US
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Telephone | 717-972-0031
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Fax |
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Provider Business Mailing Address
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Address Line | 2250 MILLENNIUM WAY STE 101
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City | ENOLA
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State | PA
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Zip | 17025-1488
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Country | US
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Telephone | 717-972-0031
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2015022255
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS040673
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License Number State | PA
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