Provider Demographics
NPI:1326450867
Name:FULLER, SHANE ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:ALAN
Last Name:FULLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71600 GARDESS RD
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8788 JAMACHA RD
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-4035
Practice Address - Country:US
Practice Address - Phone:619-515-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63426122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist