Provider Demographics
NPI:1558893164
Name:FULBRIGHT, DEVON
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:FULBRIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23139 ANGOSTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261-2619
Mailing Address - Country:US
Mailing Address - Phone:210-452-0842
Mailing Address - Fax:
Practice Address - Street 1:3301 OAKWELL CT STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-3075
Practice Address - Country:US
Practice Address - Phone:210-832-9993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-02
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX330191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice