Provider Demographics
NPI:1982617361
Name:FULLER, SANDRA (DDS)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
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 1:1515 W CORNWALLIS DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-6338
Mailing Address - Country:US
Mailing Address - Phone:336-379-1206
Mailing Address - Fax:336-379-1733
Practice Address - Street 1:1515 W CORNWALLIS DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-6338
Practice Address - Country:US
Practice Address - Phone:336-379-1206
Practice Address - Fax:336-379-1733
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC68211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice