Provider Demographics
NPI:1164078960
Name:FULLER, CALEB JONATHON (DDS)
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:JONATHON
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 1:46592 W OAK MANOR CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-5230
Mailing Address - Country:US
Mailing Address - Phone:734-233-4446
Mailing Address - Fax:
Practice Address - Street 1:46592 W OAK MANOR CT
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-5230
Practice Address - Country:US
Practice Address - Phone:734-233-4446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016003121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice