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General NPI Number Information
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NPI Number | 1437311909
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Entity Type | Individual
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Provider Name | LESLIE FULLERTON D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 06/26/2008
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Last Update Date | 06/26/2008
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Provider Practice Location Address
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Address Line | 2255 N LOOP 336 W STE D
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City | CONROE
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State | TX
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Zip | 77304-3632
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Country | US
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Telephone | 936-756-1951
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Fax |
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Provider Business Mailing Address
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Address Line | 2255 N LOOP 336 W STE D
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City | CONROE
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State | TX
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Zip | 77304-3632
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Country | US
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Telephone |
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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 | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 19458
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License Number State | TX
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