Provider Demographics
NPI:1700094158
Name:FULKERSON, BRAD LYLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:LYLE
Last Name:FULKERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:RYE
Mailing Address - State:NH
Mailing Address - Zip Code:03870-2439
Mailing Address - Country:US
Mailing Address - Phone:617-571-6951
Mailing Address - Fax:
Practice Address - Street 1:41 SPARHAWK ST
Practice Address - Street 2:
Practice Address - City:AMESBURY
Practice Address - State:MA
Practice Address - Zip Code:01913
Practice Address - Country:US
Practice Address - Phone:978-388-3505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21905122300000X
390200000X
MADN219051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program