Provider Demographics
NPI:1417152190
Name:FULLER, ANNA TYSON (DMD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:TYSON
Last Name:FULLER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 GARNERS FERRY RD STE X
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1632
Mailing Address - Country:US
Mailing Address - Phone:803-661-8412
Mailing Address - Fax:
Practice Address - Street 1:6420 GARNERS FERRY RD STE X
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1632
Practice Address - Country:US
Practice Address - Phone:803-528-8351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2023-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC43341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice