Provider Demographics
NPI:1225185515
Name:FULKERSON, BRADLEY TODD (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:TODD
Last Name:FULKERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700A BARRETT BLVD
Mailing Address - Street 2:P.O. BOX 276
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-4931
Mailing Address - Country:US
Mailing Address - Phone:270-827-5522
Mailing Address - Fax:270-827-8272
Practice Address - Street 1:700A BARRETT BLVD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-4931
Practice Address - Country:US
Practice Address - Phone:270-827-5522
Practice Address - Fax:270-827-8272
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY70401223P0221X, 122300000X
IN12009862A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist