Basic Information
| Provider Information | |||||||||
| NPI: | 1023176591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FULLER | ||||||||
| OtherFirstName: | GREGORY | ||||||||
| OtherMiddleName: | P | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DDS | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9885 E CINNABAR AVE | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5209070719 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 128 MEDWAY RD STE 2&3 | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017572915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813251091 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D2547 | AZ | N | Dental Providers | Dentist | 1223G0001X | D2547 | AZ | N | Dental Providers | Dentist | General Practice | 122300000X | DN1859342 | MA | Y | Dental Providers | Dentist |
No ID Information.