Individual
JACK ALAN FULLWILER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1223 N GOVERNMENT WAY, COEUR D ALENE, ID 83814
(208) 664-9225
(208) 667-3699
Mailing address
1223 N GOVERNMENT WAY, COEUR D ALENE, ID 83814
(208) 664-9225
(208) 667-3699
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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