Provider Demographics
NPI:1417999509
Name:FULLER, RONALD L (DDS)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:L
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 1:255 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:AINSWORTH
Mailing Address - State:NE
Mailing Address - Zip Code:69210-1420
Mailing Address - Country:US
Mailing Address - Phone:402-387-2404
Mailing Address - Fax:402-387-2410
Practice Address - Street 1:255 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:AINSWORTH
Practice Address - State:NE
Practice Address - Zip Code:69210-1420
Practice Address - Country:US
Practice Address - Phone:402-387-2404
Practice Address - Fax:402-387-2410
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE59081223G0001X
WI5900-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
BF6674053OtherDEA #