| NPI | 1730457763 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRAD TODD FULKERSON Owner 270-827-5522 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: KY 7040) |
| Additional Taxonomies | 122300000X Dentist (Licence: IN 12009862) |
| Enumeration Date | 2011-12-05 |
| Last Update Date | 2011-12-05 |