Provider Demographics
NPI:1366936783
Name:PEAK DENTAL IMPLANT SOLUTIONS
Entity type:Organization
Organization Name:PEAK DENTAL IMPLANT SOLUTIONS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:FULKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-388-3505
Mailing Address - Street 1:41 SPARHAWK ST
Mailing Address - Street 2:
Mailing Address - City:AMESBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01913-3317
Mailing Address - Country:US
Mailing Address - Phone:978-388-3505
Mailing Address - Fax:
Practice Address - Street 1:282 ELM ST
Practice Address - Street 2:
Practice Address - City:AMESBURY
Practice Address - State:MA
Practice Address - Zip Code:01913-4320
Practice Address - Country:US
Practice Address - Phone:978-388-3505
Practice Address - Fax:978-388-6363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-19
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X, 1223G0001X
MADN21905261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1700094158OtherNPI