Provider Demographics
NPI:1669869087
Name:MICHAEL T. FULBRIGHT DDS A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MICHAEL T. FULBRIGHT DDS A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FULBRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-316-4477
Mailing Address - Street 1:1815 VIA EL PRADO
Mailing Address - Street 2:#200
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5722
Mailing Address - Country:US
Mailing Address - Phone:310-316-4477
Mailing Address - Fax:
Practice Address - Street 1:1815 VIA EL PRADO
Practice Address - Street 2:#200
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5722
Practice Address - Country:US
Practice Address - Phone:310-316-4477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
CA47892122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty