Provider Demographics
NPI:1518222314
Name:FULKS, BRENT ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ALAN
Last Name:FULKS
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:W9430 H LUCAS DR
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-9409
Mailing Address - Country:US
Mailing Address - Phone:517-896-8130
Mailing Address - Fax:
Practice Address - Street 1:W9430 H LUCAS DR
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-9409
Practice Address - Country:US
Practice Address - Phone:517-896-8130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-08
Last Update Date:2012-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020725122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist