Provider Demographics
NPI:1902018328
Name:FULMORE, ZACHARIAH RONALD (DMD)
Entity Type:Individual
Prefix:DR
First Name:ZACHARIAH
Middle Name:RONALD
Last Name:FULMORE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 NICKLEBY WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-4066
Mailing Address - Country:US
Mailing Address - Phone:502-245-3280
Mailing Address - Fax:
Practice Address - Street 1:3606 KLONDIKE LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-1711
Practice Address - Country:US
Practice Address - Phone:502-451-3931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice