Provider Demographics
NPI:1255344149
Name:FULLER, RALPH S JR (DDS)
Entity type:Individual
Prefix:DR
First Name:RALPH
Middle Name:S
Last Name:FULLER
Suffix:JR
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:PO BOX 5117
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78763-5117
Mailing Address - Country:US
Mailing Address - Phone:512-478-0622
Mailing Address - Fax:512-478-8725
Practice Address - Street 1:1605 WEST AVE STE A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1555
Practice Address - Country:US
Practice Address - Phone:512-478-0622
Practice Address - Fax:512-478-8725
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice