Provider Demographics
NPI:1639397615
Name:FULLER AVENUE DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:FULLER AVENUE DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:VISSCHER-WORST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-363-1136
Mailing Address - Street 1:2755 FULLER AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3780
Mailing Address - Country:US
Mailing Address - Phone:616-363-1136
Mailing Address - Fax:616-363-4345
Practice Address - Street 1:2755 FULLER AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3780
Practice Address - Country:US
Practice Address - Phone:616-363-1136
Practice Address - Fax:616-363-4345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI166151223G0001X
MI104281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty