Provider Demographics
NPI:1073903860
Name:ZENOVIA FULTON, DMD, PA
Entity Type:Organization
Organization Name:ZENOVIA FULTON, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ZENOVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FULTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-743-0900
Mailing Address - Street 1:6476 FORT CAROLINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-2042
Mailing Address - Country:US
Mailing Address - Phone:904-743-0900
Mailing Address - Fax:904-743-4645
Practice Address - Street 1:6476 FORT CAROLINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-2042
Practice Address - Country:US
Practice Address - Phone:904-743-0900
Practice Address - Fax:904-743-4645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-31
Last Update Date:2015-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13608122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003826000Medicaid