=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457078677
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IAN FULLER DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2022
-----------------------------------------------------
Last Update Date | 01/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2241 CENTRAL AVE STE B
-----------------------------------------------------
City | ALAMEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94501-4430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-865-4400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2159 ENCINAL AVE
-----------------------------------------------------
City | ALAMEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94501-4321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | DDS108278
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------