Provider Demographics
NPI:1225148158
Name:FULTON, DANIEL ELLIOT JR (DDS PA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ELLIOT
Last Name:FULTON
Suffix:JR
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 1:8457 JOHNNY BAILEY RD BAILEY MS 39320
Mailing Address - Street 2:
Mailing Address - City:BAILEY
Mailing Address - State:MS
Mailing Address - Zip Code:39320
Mailing Address - Country:US
Mailing Address - Phone:601-681-6260
Mailing Address - Fax:
Practice Address - Street 1:HWY 39 S CHURCH STREET
Practice Address - Street 2:
Practice Address - City:DEXALB
Practice Address - State:MS
Practice Address - Zip Code:39328
Practice Address - Country:US
Practice Address - Phone:601-743-5921
Practice Address - Fax:601-743-5933
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1642 74122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist