Provider Demographics
NPI:1710137690
Name:FULLER, CAMERON (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:CAMERON
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 FORD ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-3916
Mailing Address - Country:US
Mailing Address - Phone:909-793-4326
Mailing Address - Fax:909-793-4339
Practice Address - Street 1:1481 FORD ST
Practice Address - Street 2:SUITE 101
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-3916
Practice Address - Country:US
Practice Address - Phone:909-793-4326
Practice Address - Fax:909-793-4339
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA553441223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry