Provider Demographics
NPI:1801864087
Name:FULLER, RICHARD BRUCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BRUCE
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 1:3324 PROMENADE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-2259
Mailing Address - Country:US
Mailing Address - Phone:651-452-5511
Mailing Address - Fax:651-405-0677
Practice Address - Street 1:3324 PROMENADE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-2259
Practice Address - Country:US
Practice Address - Phone:651-452-5511
Practice Address - Fax:651-405-0677
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND87741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice