Provider Demographics
NPI:1073178141
Name:FULGHAM, KELLY (RDH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FULGHAM
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3443 BAILEY CREEK CV S
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-9710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1723 KIRBY PKWY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-4367
Practice Address - Country:US
Practice Address - Phone:901-757-9696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-04
Last Update Date:2019-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6540124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist