Provider Demographics
NPI:1144296302
Name:FULLER-EDMONDS, CAROLE (DMD)
Entity type:Individual
Prefix:DR
First Name:CAROLE
Middle Name:
Last Name:FULLER-EDMONDS
Suffix:
Gender:F
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:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:PISGAH
Mailing Address - State:AL
Mailing Address - Zip Code:35765-0309
Mailing Address - Country:US
Mailing Address - Phone:256-593-0035
Mailing Address - Fax:256-593-9101
Practice Address - Street 1:201 N MAIN ST
Practice Address - Street 2:SUITE J
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-1601
Practice Address - Country:US
Practice Address - Phone:256-593-0035
Practice Address - Fax:256-593-9101
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4276122300000X
AL4276 AL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN135433OtherBCBS-DENTAL
AL51090809OtherBCBS - DENTAL
AL009006500Medicaid
AL630980899OtherDELTA USA
AL887635OtherUNITED CONCORDOA - DENTAL