Provider Demographics
NPI:1730619495
Name:FULTON, JOSHUA (DDS)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:FULTON
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 1:1704 S CLEVELAND AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-3903
Mailing Address - Country:US
Mailing Address - Phone:605-331-5656
Mailing Address - Fax:
Practice Address - Street 1:7897 BROAD RIVER RD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2357
Practice Address - Country:US
Practice Address - Phone:803-781-2439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD11541223G0001X
IADDS-094351223G0001X
SC93741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9374OtherSOUTH CAROLINA DENTAL LICENSE
SDD1154OtherSOUTH DAKOTA DENTAL LICENSE
IADDS-09435OtherIOWA DENTAL LICENSE