Provider Demographics
NPI:1144499302
Name:FULLER, CECIL WILLIAM SR (DMD)
Entity type:Individual
Prefix:
First Name:CECIL
Middle Name:WILLIAM
Last Name:FULLER
Suffix:SR
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 1:203 DALLAS AVE
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701
Mailing Address - Country:US
Mailing Address - Phone:334-874-4615
Mailing Address - Fax:334-874-4987
Practice Address - Street 1:203 DALLAS AVE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701
Practice Address - Country:US
Practice Address - Phone:334-874-4615
Practice Address - Fax:334-874-4987
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL92320Medicaid