Provider Demographics
NPI:1124242912
Name:ROBERT C FULLER DDS & JENNIFER R FULLER DDS
Entity type:Organization
Organization Name:ROBERT C FULLER DDS & JENNIFER R FULLER DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:R
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-864-9110
Mailing Address - Street 1:334 LIVERNOIS
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220
Mailing Address - Country:US
Mailing Address - Phone:313-864-9110
Mailing Address - Fax:313-864-8750
Practice Address - Street 1:334 LIVERNOIS
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220
Practice Address - Country:US
Practice Address - Phone:313-864-9110
Practice Address - Fax:313-864-8750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI17660122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========Medicare UPIN