Provider Demographics
NPI:1669964003
Name:FULLER, TAYLER DANYELLE (DDS)
Entity type:Individual
Prefix:DR
First Name:TAYLER
Middle Name:DANYELLE
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 1:2537 S 3RD STREET PLZ
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68108-1709
Mailing Address - Country:US
Mailing Address - Phone:208-553-6977
Mailing Address - Fax:
Practice Address - Street 1:2602 J ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-1643
Practice Address - Country:US
Practice Address - Phone:402-733-1325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-01
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-095431223G0001X
NE74611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice