Provider Demographics
NPI:1255315313
Name:FULKERSON, MICHAEL STEVEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STEVEN
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 1:2441 21ST STREET
Mailing Address - Street 2:CDR, U.S. ARMY DENTAL ACTIVITY
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5369
Mailing Address - Country:US
Mailing Address - Phone:270-798-8614
Mailing Address - Fax:270-798-8633
Practice Address - Street 1:2441 21ST STREET
Practice Address - Street 2:CDR, U.S. ARMY DENTAL ACTIVITY
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5369
Practice Address - Country:US
Practice Address - Phone:270-798-8614
Practice Address - Fax:270-798-8633
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice