Provider Demographics
NPI:1689802910
Name:FULLER, BENJAMIN LUKE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:LUKE
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 1:2825 ROSEBAY CT
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52411-4701
Mailing Address - Country:US
Mailing Address - Phone:319-321-1486
Mailing Address - Fax:
Practice Address - Street 1:835 3RD AVE SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-1810
Practice Address - Country:US
Practice Address - Phone:319-366-8377
Practice Address - Fax:319-366-7091
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK61281223S0112X
IA089861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery