Provider Demographics
NPI:1760674725
Name:FULLER, BRIAN SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:SCOTT
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 1:1920 S 1ST ST
Mailing Address - Street 2:1509
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1055
Mailing Address - Country:US
Mailing Address - Phone:612-270-0885
Mailing Address - Fax:
Practice Address - Street 1:1920 S 1ST ST
Practice Address - Street 2:1509
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1055
Practice Address - Country:US
Practice Address - Phone:612-270-0885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12089122300000X
MT2199122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist