Provider Demographics
NPI:1285641589
Name:TULLER, JEFFREY W (DDS, FICD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:W
Last Name:TULLER
Suffix:
Gender:M
Credentials:DDS, FICD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 S FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1304
Mailing Address - Country:US
Mailing Address - Phone:208-322-5655
Mailing Address - Fax:208-323-8160
Practice Address - Street 1:1201 S FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1304
Practice Address - Country:US
Practice Address - Phone:208-322-5655
Practice Address - Fax:208-323-8160
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD20651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice