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NPI Code Detail

MEDICARE: DR. ELLIS LAMAR FULLER D.D.S

MEDICARE: DR. ELLIS LAMAR FULLER D.D.S
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1122300000XDentistDN15405FL

General Provider Information

NPI Number : 1366466286
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ELLIS LAMAR FULLER D.D.S
Provider Business Mailing Address
First Line : 1287 BLESSING ST
Second Line :
City : MAITLAND
State : FL
Zip : 32751-4260
Country : US
Telephone Number : 407-838-0101
Fax Number :
Provider Business Practice Location Address
First Line : 114 TIMBERLACHEN CIR
Second Line :
City : LAKE MARY
State : FL
Zip : 32746-3395
Country : US
Telephone Number : 407-330-3801
Fax Number : 407-330-5739
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/26/2006
Last Update Date : 06/26/2012

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