Provider Demographics
NPI:1023064037
Name:FULLER, JANIS LEA (DDS)
Entity type:Individual
Prefix:DR
First Name:JANIS
Middle Name:LEA
Last Name:FULLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JANIS
Other - Middle Name:LEA
Other - Last Name:STEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1230 ALVERSER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2653
Mailing Address - Country:US
Mailing Address - Phone:804-594-2570
Mailing Address - Fax:804-594-2844
Practice Address - Street 1:1230 ALVERSER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2653
Practice Address - Country:US
Practice Address - Phone:804-594-2570
Practice Address - Fax:804-594-2844
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010063971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice