Provider Demographics
NPI:1639401334
Name:FULLER, SHAWN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:
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 1:193 BOSTON TPKE STE 6140
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-2552
Mailing Address - Country:US
Mailing Address - Phone:508-669-7140
Mailing Address - Fax:508-669-7140
Practice Address - Street 1:193 BOSTON TPKE STE 6140
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545
Practice Address - Country:US
Practice Address - Phone:508-669-7140
Practice Address - Fax:508-669-7140
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857804122300000X
AZ7840122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist