Provider Demographics
NPI:1689310831
Name:FULLENKAMP, RHIANNON (DMD)
Entity Type:Individual
Prefix:
First Name:RHIANNON
Middle Name:
Last Name:FULLENKAMP
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:RHIANNON
Other - Middle Name:
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21 WESCOTT CT
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1099 N MAIN ST # 102
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7300
Practice Address - Country:US
Practice Address - Phone:843-536-8577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10154122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist