Provider Demographics
NPI:1891821765
Name:FULLER, CLAYTON SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLAYTON
Middle Name:SCOTT
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 1:589 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5619
Mailing Address - Country:US
Mailing Address - Phone:619-422-3223
Mailing Address - Fax:619-422-7777
Practice Address - Street 1:589 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5619
Practice Address - Country:US
Practice Address - Phone:619-422-3223
Practice Address - Fax:619-422-7777
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA341011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB34101-01OtherDENTI-CAL