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General NPI Number Information
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NPI Number | 1760674725
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Entity Type | Individual
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Provider Name | BRIAN SCOTT FULLER D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 08/14/2007
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Last Update Date | 08/14/2007
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Provider Practice Location Address
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Address Line | 1920 S 1ST ST 1509
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City | MINNEAPOLIS
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State | MN
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Zip | 55454-1055
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Country | US
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Telephone | 612-270-0885
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Fax |
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Provider Business Mailing Address
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Address Line | 1920 S 1ST ST 1509
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City | MINNEAPOLIS
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State | MN
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Zip | 55454-1055
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Country | US
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Telephone | 612-270-0885
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | D12089
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2199
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License Number State | MT
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