Provider Demographics
NPI:1578688545
Name:FULLER, ADAM FREDRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:FREDRICK
Last Name:FULLER
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 1:3223 E 29TH STREET
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50317
Mailing Address - Country:US
Mailing Address - Phone:515-266-2128
Mailing Address - Fax:
Practice Address - Street 1:3223 E 29TH STREET
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50317
Practice Address - Country:US
Practice Address - Phone:515-266-2128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08213122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1649447OtherUNITED CONCORDIA
IA0421883Medicaid