Provider Demographics
NPI:1376566976
Name:FULLER, JON GORDON JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:GORDON
Last Name:FULLER
Suffix:JR
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 1:570 W 400 N
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2236
Mailing Address - Country:US
Mailing Address - Phone:435-259-4333
Mailing Address - Fax:435-259-6618
Practice Address - Street 1:570 W 400 N
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2236
Practice Address - Country:US
Practice Address - Phone:435-259-4333
Practice Address - Fax:435-259-6618
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT142288-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice