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General NPI Number Information
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NPI Number | 1497276729
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Entity Type | Organization
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Legal Business Name | FAMILY & RESTORATIVE DENTISTRY
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Dates
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Enumeration Date | 06/27/2017
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 7137 236TH AVE STE 108
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City | SALEM
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State | WI
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Zip | 53168-8975
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Country | US
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Telephone | 262-843-4643
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Fax |
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Provider Business Mailing Address
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Address Line | 7137 236TH AVE STE 108
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City | SALEM
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State | WI
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Zip | 53168-8975
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Country | US
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Telephone | 262-843-4643
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. JAMES C FULMER
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Credential | DDS
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Telephone | 262-945-2084
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 3667
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License Number State | WI
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