Provider Demographics
NPI:1962559328
Name:FULTZ, RODNEY BRENT (DMD DENTIST)
Entity type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:BRENT
Last Name:FULTZ
Suffix:
Gender:M
Credentials:DMD DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6616 DIXIE HWY #1
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-2166
Mailing Address - Country:US
Mailing Address - Phone:859-371-3950
Mailing Address - Fax:
Practice Address - Street 1:1813 WEST BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-0000
Practice Address - Country:US
Practice Address - Phone:502-772-7531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY52421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6005242000Medicaid