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Individual
JACK ALAN FULLWILER
Active
Individual
JACK ALAN FULLWILER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
D1747
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010009552
REGENCE BLUE SHIELD
—
01
—
07068
WASHINGTON DENT SERV
—
Enumeration date
03/01/2007
Last updated
07/08/2007
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