Provider Demographics
NPI:1497276729
Name:FAMILY & RESTORATIVE DENTISTRY
Entity Type:Organization
Organization Name:FAMILY & RESTORATIVE DENTISTRY
Other - Org Name:FULMER DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:FULMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-945-2084
Mailing Address - Street 1:7137 236TH AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:53168-8975
Mailing Address - Country:US
Mailing Address - Phone:262-843-4643
Mailing Address - Fax:
Practice Address - Street 1:7137 236TH AVE STE 108
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:WI
Practice Address - Zip Code:53168-8975
Practice Address - Country:US
Practice Address - Phone:262-843-4643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3667261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental