Provider Demographics
NPI:1548344757
Name:FULLER, JOESPH WARREN III (DDS)
Entity type:Individual
Prefix:DR
First Name:JOESPH
Middle Name:WARREN
Last Name:FULLER
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 NORTH CENTER STREET
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32347
Mailing Address - Country:US
Mailing Address - Phone:850-584-4613
Mailing Address - Fax:850-584-9009
Practice Address - Street 1:1204 N CENTER ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32347-2038
Practice Address - Country:US
Practice Address - Phone:850-584-4613
Practice Address - Fax:850-584-9009
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN081661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice