Provider Demographics
NPI:1710021415
Name:ULLOM, VIRGIL (DDS)
Entity Type:Individual
Prefix:DR
First Name:VIRGIL
Middle Name:
Last Name:ULLOM
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 1:245 BABSON DR
Mailing Address - Street 2:
Mailing Address - City:BABSON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33827-9516
Mailing Address - Country:US
Mailing Address - Phone:863-638-2228
Mailing Address - Fax:
Practice Address - Street 1:1 SCENIC CENTRAL STE 107
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-6107
Practice Address - Country:US
Practice Address - Phone:863-678-1939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN90721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice