Individual provider · NPI-1

Jackson Fuller, DDS

Dentist, General Practice · Highland Village, TX

NPI number1619549862
StatusActive
Last updated in NPPESJan 2, 2025

Details

NPI
1619549862
Entity type
Individual (NPI-1)
Name
Jackson Fuller
Credential
DDS
Sex
Male
Sole proprietor
No
Enumeration date
Jul 15, 2021
Certification date
Jan 2, 2025
Last updated
Jan 2, 2025

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
1223G0001X Dentist, General Practice39355TXYes

Practice location

2600 Village Pkwy Ste 120
Highland Village, TX 75077-3285

Phone 469-444-6500

Mailing address

2600 Village Pkwy Ste 120
Highland Village, TX 75077-3285

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