=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316234735
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EHLEN & FULLER DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2011
-----------------------------------------------------
Last Update Date | 07/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11208 94TH AVE E SUITE B
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98373-3663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-848-4597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11208 94TH AVE E SUITE B
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98373-3663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-848-4597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. JULIE FULLER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 253-848-4597
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE00006157
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE60100274
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------