Provider Demographics
NPI:1770629339
Name:FULLER, STEVEN CRAIG (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:CRAIG
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 1:2822 E 29TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50317-8720
Mailing Address - Country:US
Mailing Address - Phone:515-266-3437
Mailing Address - Fax:515-266-4313
Practice Address - Street 1:2822 E 29TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50317-8720
Practice Address - Country:US
Practice Address - Phone:515-266-3437
Practice Address - Fax:515-266-4313
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0168088Medicaid