Provider Demographics
NPI:1689146920
Name:RAELENE FULFORD DDS PLLC
Entity Type:Organization
Organization Name:RAELENE FULFORD DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAELENE
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:FULFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-771-7971
Mailing Address - Street 1:110 OLD LARAMIE TRL STE 105
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-7010
Mailing Address - Country:US
Mailing Address - Phone:909-771-7971
Mailing Address - Fax:
Practice Address - Street 1:110 OLD LARAMIE TRL STE 105
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-7010
Practice Address - Country:US
Practice Address - Phone:909-771-7971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental