Provider Demographics
NPI:1326051707
Name:SANDRA L. FULLER,DDS,P.A.
Entity Type:Organization
Organization Name:SANDRA L. FULLER,DDS,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-379-1206
Mailing Address - Street 1:1515 W CORNWALLIS DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-6338
Mailing Address - Country:US
Mailing Address - Phone:336-379-1206
Mailing Address - Fax:336-379-1733
Practice Address - Street 1:1515 W CORNWALLIS DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-6338
Practice Address - Country:US
Practice Address - Phone:336-379-1206
Practice Address - Fax:336-379-1733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC68211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty