Individual
DR. FORREST WANE FULLENKAMP
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1020 SOUTHAMPTON DR, DECATUR, IN 46733-1049
(260) 724-8410
Mailing address
1020 SOUTHAMPTON DR, DECATUR, IN 46733-1049
(260) 724-8410
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
12013196A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12013196A
INDIANA PROFESSIONAL LICENSING AGENCY
IN
Enumeration date
07/25/2019
Last updated
04/29/2024
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