Provider Demographics
NPI:1730457763
Name:BRAD T FULKERSON, DMD,MSD,LLC
Entity Type:Organization
Organization Name:BRAD T FULKERSON, DMD,MSD,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:FULKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-827-5522
Mailing Address - Street 1:700A BARRETT BLVD
Mailing Address - Street 2:P.O. BOX 276
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-4931
Mailing Address - Country:US
Mailing Address - Phone:270-827-5522
Mailing Address - Fax:270-827-8272
Practice Address - Street 1:700A BARRETT BLVD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-4931
Practice Address - Country:US
Practice Address - Phone:270-827-5522
Practice Address - Fax:270-827-8272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009862122300000X
KY70401223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty