Provider Demographics
NPI:1558911651
Name:FULTON, JULIE DIANE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:DIANE
Last Name:FULTON
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:PO BOX 412
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-0412
Mailing Address - Country:US
Mailing Address - Phone:760-362-3703
Mailing Address - Fax:
Practice Address - Street 1:423 CORPORAL EVANS RD
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93944-3403
Practice Address - Country:US
Practice Address - Phone:831-242-5612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26281124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist