Provider Demographics
NPI:1972816221
Name:FULLER, MICHAEL DANIEL (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DANIEL
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 1:7760 W VOICE OF AMERICA PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-3371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7760 W VOICE OF AMERICA PARK DR STE A
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-3371
Practice Address - Country:US
Practice Address - Phone:513-759-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30-0234121223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program