MEDICARE: MICHAEL T. FULBRIGHT DDS A PROFESSIONAL CORPORATION

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	332BC3200X	Customized Equipment (DME)
2	122300000X	Dentist	47892	CA

General Provider Information

NPI Number	:	1669869087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL T. FULBRIGHT DDS A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	1815 VIA EL PRADO
Second Line	:	#200
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5722
Country	:	US
Telephone Number	:	310-316-4477
Fax Number	:

Provider Business Practice Location Address
First Line	:	1815 VIA EL PRADO
Second Line	:	#200
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5722
Country	:	US
Telephone Number	:	310-316-4477
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	MR. MICHAEL FULBRIGHT
Credential	:	DDS
Telephone Number	:	310-316-4477

Provider Enumeration Date	:	04/23/2015
Last Update Date	:	10/14/2015

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