=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255344149
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RALPH S. FULLER JR. DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1605 WEST AVE STE A
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78701-1555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-478-0622
-----------------------------------------------------
Fax | 512-478-8725
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5117
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78763-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-478-0622
-----------------------------------------------------
Fax | 512-478-8725
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 10590
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------