Basic Information
| Provider Information | |||||||||
| NPI: | 1639401334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 193 BOSTON TPKE STE 6140 | ||||||||
| Address2: | |||||||||
| City: | SHREWSBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015452552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086697140 | ||||||||
| FaxNumber: | 5086697140 | ||||||||
| Practice Location | |||||||||
| Address1: | 193 BOSTON TPKE STE 6140 | ||||||||
| Address2: | |||||||||
| City: | SHREWSBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086697140 | ||||||||
| FaxNumber: | 5086697140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2010 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN1857804 | MA | Y | Dental Providers | Dentist | 122300000X | 7840 | AZ | N | Dental Providers | Dentist |
No ID Information.