Provider Demographics
NPI:1629112057
Name:FULTON, DEBRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:
Last Name:FULTON
Suffix:
Gender:F
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:PO BOX 2742
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-0742
Mailing Address - Country:US
Mailing Address - Phone:419-841-0656
Mailing Address - Fax:
Practice Address - Street 1:817 FEDERAL ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1539
Practice Address - Country:US
Practice Address - Phone:856-583-2496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI027347001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0696813Medicaid
OH18632OtherOHIO STATE DENTAL LICENSE