Provider Demographics
NPI:1083702443
Name:FULGHAM, JOE BRYAN JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:BRYAN
Last Name:FULGHAM
Suffix:JR
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:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:BROWNSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75756-0517
Mailing Address - Country:US
Mailing Address - Phone:903-852-3278
Mailing Address - Fax:903-852-3418
Practice Address - Street 1:14268 HIGHWAY 31
Practice Address - Street 2:
Practice Address - City:BROWNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75756-0517
Practice Address - Country:US
Practice Address - Phone:903-852-3278
Practice Address - Fax:903-852-3418
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10399122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist