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General NPI Number Information
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NPI Number | 1881021020
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Entity Type | Organization
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Legal Business Name | FULLWOOD DENTAL CLINIC, LLC
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Dates
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Enumeration Date | 10/02/2013
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Last Update Date | 10/02/2013
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Provider Practice Location Address
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Address Line | 485 MULBERRY AVE
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City | SELMER
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State | TN
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Zip | 38375-2307
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Country | US
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Telephone | 731-645-7785
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Fax |
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Provider Business Mailing Address
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Address Line | 485 MULBERRY AVE
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City | SELMER
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State | TN
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Zip | 38375-2307
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Country | US
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Telephone | 731-645-7785
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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. RONNIE L FULLWOOD
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Credential | D.D.S.
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Telephone | 731-645-7785
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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 | 9500
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License Number State | TN
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