Provider Demographics
NPI:1174970271
Name:FULL, JOHN (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:FULL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 MEDICAL CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-3669
Mailing Address - Country:US
Mailing Address - Phone:717-817-3235
Mailing Address - Fax:
Practice Address - Street 1:90 MEDICAL CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-3669
Practice Address - Country:US
Practice Address - Phone:910-269-2420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC115621223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program