MEDICARE: DR. BRET FULLENKAMP D.M.D.

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
1	1223G0001X	General Practice Dentistry	30-023440	OH

General Provider Information

NPI Number	:	1376824599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRET FULLENKAMP D.M.D.

Provider Business Mailing Address
First Line	:	2591 MIAMISBURG CENTERVILLE RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45459-3711
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2591 MIAMISBURG CENTERVILLE RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45459-3711
Country	:	US
Telephone Number	:	937-434-3757
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2011
Last Update Date	:	01/16/2013

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