Provider Demographics
NPI:1154706380
Name:FULLEM, CHARLES MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:FULLEM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 MILLENNIUM WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:ENOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17025-1488
Mailing Address - Country:US
Mailing Address - Phone:717-972-0031
Mailing Address - Fax:
Practice Address - Street 1:2250 MILLENNIUM WAY STE 101
Practice Address - Street 2:
Practice Address - City:ENOLA
Practice Address - State:PA
Practice Address - Zip Code:17025-1488
Practice Address - Country:US
Practice Address - Phone:717-972-0031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015022255122300000X
PADS040673122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist