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General NPI Number Information
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NPI Number | 1639397615
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Entity Type | Organization
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Legal Business Name | FULLER AVENUE DENTAL ASSOCIATES
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Dates
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Enumeration Date | 04/23/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2755 FULLER AVE NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49505-3780
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Country | US
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Telephone | 616-363-1136
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Fax | 616-363-4345
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Provider Business Mailing Address
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Address Line | 2755 FULLER AVE NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49505-3780
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Country | US
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Telephone | 616-363-1136
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Fax | 616-363-4345
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. SHANNON MARIE VISSCHER-WORST
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Credential |
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Telephone | 616-363-1136
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 10428
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 16615
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License Number State | MI
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