Provider Demographics
NPI:1184177941
Name:FULLER, ALEXANDRA DEE (DDS)
Entity type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:DEE
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 1:5683 WAGNER HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:AVOCA
Mailing Address - State:NY
Mailing Address - Zip Code:14809
Mailing Address - Country:US
Mailing Address - Phone:585-314-9095
Mailing Address - Fax:
Practice Address - Street 1:625 ELMWOOD AVE
Practice Address - Street 2:BOX 683
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620
Practice Address - Country:US
Practice Address - Phone:585-275-8315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY059108-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program