Provider Demographics
NPI:1881180974
Name:FULLER, HAYDEN (DDS)
Entity Type:Individual
Prefix:
First Name:HAYDEN
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 HUNTLEIGH DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-3806
Mailing Address - Country:US
Mailing Address - Phone:405-414-7481
Mailing Address - Fax:
Practice Address - Street 1:4320 MCAULEY BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8386
Practice Address - Country:US
Practice Address - Phone:405-755-4826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6853122300000X
OK811223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentist