Provider Demographics
NPI:1730733007
Name:FULLENKAMP, FORREST WANE (DDS)
Entity type:Individual
Prefix:DR
First Name:FORREST
Middle Name:WANE
Last Name:FULLENKAMP
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 1:1020 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:2019-07-25
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013196A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12013196AOtherINDIANA PROFESSIONAL LICENSING AGENCY