Provider Demographics
NPI:1871679852
Name:FULLER, NOEL PHILLIPS (DMD, PA)
Entity Type:Individual
Prefix:DR
First Name:NOEL
Middle Name:PHILLIPS
Last Name:FULLER
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 EBENEZER RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-3391
Mailing Address - Country:US
Mailing Address - Phone:803-324-2919
Mailing Address - Fax:803-324-2918
Practice Address - Street 1:1380 EBENEZER RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732
Practice Address - Country:US
Practice Address - Phone:803-324-2919
Practice Address - Fax:803-324-2918
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17991223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics