Provider Demographics
NPI:1528087467
Name:FULMER, JOHN H JR (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:FULMER
Suffix:JR
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 1:900A MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-4063
Mailing Address - Country:US
Mailing Address - Phone:843-488-3710
Mailing Address - Fax:
Practice Address - Street 1:900A MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4063
Practice Address - Country:US
Practice Address - Phone:843-488-3710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC24081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZZ2408Medicaid
NC7992952Medicaid