Fullwiler, Jack Alan

Fullwiler, Jack Alan is an individual health care provider with primary practice located at 1223 N Government Way , Coeur D Alene ID 83814. He recently has only one registered license in Dental Providers / Dentist, which is considered as his primary health care specialty. Fullwiler, Jack Alan can be contacted via phone (208) 664-9225.

Contact Information

Primary practice address
1223 N Government Way Coeur D Alene ID 83814
Phone: (208) 664-9225
Fax: (208) 667-3699
Website:
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Health care specialties

SpecialtyCodeLicense #State
Dental Providers / Dentist 122300000X D1747 Idaho

Profile Details

NPI number 1518095678
LBN Legal business name Fullwiler, Jack Alan
Credentials Doctor of Dental Surgery (DDS)
Entity Individual
Sole proprietor 1 No
Enumeration date Mar 1st, 2007
Last updated Jul 8th, 2007 - about 18 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1518095678 NPPES
Other 000010009552 REGENCE BLUE SHIELD
Other 07068 REGENCE BLUE SHIELD

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