Provider Demographics
NPI:1235263872
Name:FULFORD, REGINALD (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:
Last Name:FULFORD
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 EL CERRITO PLZ
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-4006
Mailing Address - Country:US
Mailing Address - Phone:510-527-7111
Mailing Address - Fax:510-527-7116
Practice Address - Street 1:511 EL CERRITO PLZ
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-4006
Practice Address - Country:US
Practice Address - Phone:510-527-7111
Practice Address - Fax:510-527-7116
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA495201223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics