Provider Demographics
NPI:1154817880
Name:GARCIA FULLE, WALLY ALESSANDRO (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALLY ALESSANDRO
Middle Name:
Last Name:GARCIA FULLE
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 1:700 8TH AVE W STE 101
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-4737
Mailing Address - Country:US
Mailing Address - Phone:941-776-4000
Mailing Address - Fax:941-845-4963
Practice Address - Street 1:1312 MANATEE AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1358
Practice Address - Country:US
Practice Address - Phone:941-708-8710
Practice Address - Fax:941-708-8761
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12297390200000X
FLDN252661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program