Provider Demographics
NPI:1982863585
Name:FULLER, ANNA G (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:G
Last Name:FULLER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 E HIGHWAY 193
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-8528
Mailing Address - Country:US
Mailing Address - Phone:801-771-4505
Mailing Address - Fax:
Practice Address - Street 1:950 25TH ST STE A
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-6823
Practice Address - Country:US
Practice Address - Phone:801-395-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2990122300000X
UT8211338-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMDD2990OtherNM DENTAL LICENCE
UT8211338-992OtherUTAH DENTAL LICENCE - ANESTHESIA CLASS II PERMIT