Provider Demographics
NPI:1518157080
Name:FULLER, AMY JO (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:JO
Last Name:FULLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:JO
Other - Last Name:DETTBARN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3060 AVENUE B
Mailing Address - Street 2:SUITE A
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102
Mailing Address - Country:US
Mailing Address - Phone:406-651-4867
Mailing Address - Fax:
Practice Address - Street 1:3060 AVENUE B
Practice Address - Street 2:SUITE A
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102
Practice Address - Country:US
Practice Address - Phone:406-651-4867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTD2278122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist