Provider Demographics
NPI:1275263568
Name:FULLER, ALEXANDRA (DDS)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SW ARCHER RD # D11-6
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0426
Mailing Address - Country:US
Mailing Address - Phone:814-460-2602
Mailing Address - Fax:
Practice Address - Street 1:7505 GRAND LELY DR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34113-1753
Practice Address - Country:US
Practice Address - Phone:239-920-4523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN26999122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist