Provider Demographics
NPI:1487718847
Name:IDE, MEGAN FULMER (DDS)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:FULMER
Last Name:IDE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 N DEMAREE ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4119
Mailing Address - Country:US
Mailing Address - Phone:559-625-2744
Mailing Address - Fax:559-625-9413
Practice Address - Street 1:1045 N DEMAREE ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4119
Practice Address - Country:US
Practice Address - Phone:559-625-2744
Practice Address - Fax:559-625-9413
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA446781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice