Provider Demographics
NPI:1366466286
Name:FULLER, ELLIS LAMAR (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:LAMAR
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 1:1287 BLESSING ST
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4260
Mailing Address - Country:US
Mailing Address - Phone:407-838-0101
Mailing Address - Fax:
Practice Address - Street 1:114 TIMBERLACHEN CIR
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3395
Practice Address - Country:US
Practice Address - Phone:407-330-3801
Practice Address - Fax:407-330-5739
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15405122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist