Provider Demographics
NPI:1497815104
Name:FULLMER, FREDERICK DALE (DDS)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:DALE
Last Name:FULLMER
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 1:888 OAK GROVE AVENUE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4432
Mailing Address - Country:US
Mailing Address - Phone:650-322-8442
Mailing Address - Fax:650-322-1242
Practice Address - Street 1:888 OAK GROVE AVENUE
Practice Address - Street 2:SUITE 11
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4432
Practice Address - Country:US
Practice Address - Phone:650-322-8442
Practice Address - Fax:650-322-1242
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14290122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist