Provider Demographics
NPI:1386972974
Name:FULLER, ROBERT L (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:FULLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 S 1030 E
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-6688
Mailing Address - Country:US
Mailing Address - Phone:801-223-9887
Mailing Address - Fax:
Practice Address - Street 1:761 S 1030 E
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-6688
Practice Address - Country:US
Practice Address - Phone:801-223-9887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT136880-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist