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General NPI Number Information
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NPI Number | 1477751576
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Entity Type | Organization
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Legal Business Name | FULLER FAMILY DENTAL, PLC
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Dates
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Enumeration Date | 07/10/2007
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Last Update Date | 07/10/2007
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Provider Practice Location Address
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Address Line | 2244 LOOMIS AVE
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City | CORNING
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State | IA
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Zip | 50841
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Country | US
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Telephone | 641-322-3737
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Fax | 641-322-3377
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Provider Business Mailing Address
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Address Line | 2244 LOOMIS AVE
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City | CORNING
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State | IA
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Zip | 50841
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Country | US
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Telephone | 641-322-3737
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Fax | 641-322-3377
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Authorized Official
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Title or Position | DENTIST
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Name | DR. MARIA REYNA FULLER
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Credential | DDS
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Telephone | 641-322-3737
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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 | 08458
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License Number State | IA
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