Provider Demographics
NPI:1215660717
Name:FULK, CAITLIN GIFFORD (DMD)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:GIFFORD
Last Name:FULK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8502 OCEAN FRONT AVE # B
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-1836
Mailing Address - Country:US
Mailing Address - Phone:336-414-7186
Mailing Address - Fax:
Practice Address - Street 1:1100 VOLVO PKWY STE 110
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3341
Practice Address - Country:US
Practice Address - Phone:757-484-8262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-03
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022024401122300000X
VA0414188511223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist