Provider Demographics
NPI:1548753163
Name:FULLENKAMP, JULIE LYNN (DDS)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:LYNN
Last Name:FULLENKAMP
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SOUTHAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733-1049
Mailing Address - Country:US
Mailing Address - Phone:260-724-8410
Mailing Address - Fax:
Practice Address - Street 1:1020 SOUTHAMPTON DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-1049
Practice Address - Country:US
Practice Address - Phone:260-724-8410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC93371223G0001X
IN12012935A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice