1346763158 NPI number — POWELL PEDIATRIC DENTISTRY INGRAM PARTNERSHIP

Table of content: JENNIFER FULLER LPC, LAC, AADC, NCC (NPI 1801386230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346763158 NPI number — POWELL PEDIATRIC DENTISTRY INGRAM PARTNERSHIP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POWELL PEDIATRIC DENTISTRY INGRAM PARTNERSHIP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346763158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7761 N INGRAM AVE
Provider Second Line Business Mailing Address:
SUITE #101
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-431-9701
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7761 N INGRAM AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-431-9701
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
POWELL
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
559-321-1833

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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