Provider Demographics
NPI:1205972163
Name:FULLER, J. BARDEN (DDS)
Entity type:Individual
Prefix:DR
First Name:J.
Middle Name:BARDEN
Last Name:FULLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 MERIDEN-WATERBURY TPKE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PLANTSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06479
Mailing Address - Country:US
Mailing Address - Phone:860-426-0997
Mailing Address - Fax:860-426-0669
Practice Address - Street 1:1090 MERIDEN WATERBURY TURNPIKE
Practice Address - Street 2:SUITE 2
Practice Address - City:PLANTSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06479-2055
Practice Address - Country:US
Practice Address - Phone:860-426-0997
Practice Address - Fax:860-426-0669
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT59601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice