Provider Demographics
NPI:1477751576
Name:FULLER FAMILY DENTAL, PLC
Entity Type:Organization
Organization Name:FULLER FAMILY DENTAL, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNA FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:641-322-3737
Mailing Address - Street 1:2244 LOOMIS AVE
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:IA
Mailing Address - Zip Code:50841
Mailing Address - Country:US
Mailing Address - Phone:641-322-3737
Mailing Address - Fax:641-322-3377
Practice Address - Street 1:2244 LOOMIS AVE
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:IA
Practice Address - Zip Code:50841
Practice Address - Country:US
Practice Address - Phone:641-322-3737
Practice Address - Fax:641-322-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08458122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty