MEDICARE: FULLER & ASSOCIATES 11, PLLC

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

General Provider Information

NPI Number	:	1427766112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULLER & ASSOCIATES 11, PLLC

Provider Business Mailing Address
First Line	:	3450 FORESTDALE DR
Second Line	:
City	:	BURLINGTON
State	:	NC
Zip	:	27215-9142
Country	:	US
Telephone Number	:	336-586-5010
Fax Number	:

Provider Business Practice Location Address
First Line	:	8015 CREEDMOOR RD STE 202
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27613-4397
Country	:	US
Telephone Number	:	919-847-8747
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RAWLEY H FULLER IV
Credential	:	DDS
Telephone Number	:	336-213-0549

Provider Enumeration Date	:	11/10/2022
Last Update Date	:	11/10/2022

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