Provider Demographics
NPI:1023176591
Name:FULLER, GREGORY PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:PAUL
Last Name:FULLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:GREGORY
Other - Middle Name:P
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:9885 E CINNABAR AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4737
Mailing Address - Country:US
Mailing Address - Phone:520-907-0719
Mailing Address - Fax:
Practice Address - Street 1:128 MEDWAY RD STE 2&3
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-2915
Practice Address - Country:US
Practice Address - Phone:781-325-1091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD2547122300000X, 1223G0001X
MADN1859342122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice