Provider Demographics
NPI:1376095885
Name:ANNA T. FULLER, DMD, LLC
Entity Type:Organization
Organization Name:ANNA T. FULLER, DMD, LLC
Other - Org Name:FRIENDLY DENTAL OF COLUMBIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:T
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-528-8351
Mailing Address - Street 1:145 PELHAM DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1321
Mailing Address - Country:US
Mailing Address - Phone:803-602-3862
Mailing Address - Fax:
Practice Address - Street 1:145 PELHAM DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1321
Practice Address - Country:US
Practice Address - Phone:803-602-3862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty