Provider Demographics
NPI:1770009474
Name:UNIVERSITY POINTE ENDODONTICS MICHAEL FULLER D.D.S. M.S. LLC
Entity Type:Organization
Organization Name:UNIVERSITY POINTE ENDODONTICS MICHAEL FULLER D.D.S. M.S. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-807-4128
Mailing Address - Street 1:7760 W VOICE OF AMERICA PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-3371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7760 W VOICE OF AMERICA PARK DR STE A
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-3371
Practice Address - Country:US
Practice Address - Phone:513-759-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0234121223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty