Provider Demographics
NPI:1215000864
Name:FULLER, RAWLEY HARRISON IV (DDS, PA)
Entity Type:Individual
Prefix:DR
First Name:RAWLEY
Middle Name:HARRISON
Last Name:FULLER
Suffix:IV
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 FORESTDALE DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-9142
Mailing Address - Country:US
Mailing Address - Phone:336-226-0855
Mailing Address - Fax:336-226-0137
Practice Address - Street 1:3450 FORESTDALE DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-9142
Practice Address - Country:US
Practice Address - Phone:336-226-0855
Practice Address - Fax:336-226-0137
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC64911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8992953Medicaid