Provider Demographics
NPI:1669846861
Name:FULLER & SPENCER FULLER, PC
Entity Type:Organization
Organization Name:FULLER & SPENCER FULLER, PC
Other - Org Name:THE LEESBURG DENTISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LLEWELLYN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WELSTEAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-771-8500
Mailing Address - Street 1:706 S KING ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-3918
Mailing Address - Country:US
Mailing Address - Phone:703-771-8500
Mailing Address - Fax:703-771-9541
Practice Address - Street 1:706 S KING ST
Practice Address - Street 2:SUITE 5
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-3918
Practice Address - Country:US
Practice Address - Phone:703-771-8500
Practice Address - Fax:703-771-9541
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POTOMAC VALLEY DENTAL CARE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-25
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty