Provider Demographics
NPI:1518095678
Name:FULLWILER, JACK ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ALAN
Last Name:FULLWILER
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 1:1223 N GOVERNMENT WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-664-9225
Mailing Address - Fax:208-667-3699
Practice Address - Street 1:1223 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-664-9225
Practice Address - Fax:208-667-3699
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010009552OtherREGENCE BLUE SHIELD
07068OtherWASHINGTON DENT SERV