Fuller Avenue Dental Associates

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

16615 Issued in MI

Legal business name

FULLER AVENUE DENTAL ASSOCIATES

Practice address

2755 Fuller Ave NE
Grand Rapids, MI 49505-3780

Phone

(616) 363-1136

Fax

(616) 363-4345

NPI assigned

Apr 23, 2007

Last updated

Aug 22, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Shannon Marie Visscher-Worst

Title

Office Manager

Phone

(616) 363-1136

Specialties & licenses 2

Addresses

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Esther Jimenez, D.D.S

  • General Practice Dentistry
  • Grand Rapids, MI
  • NPI 1669585303
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1177286400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1639397615",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2755 FULLER AVE NE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495053780",
            "telephone_number": "616-363-1136",
            "fax_number": "616-363-4345"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2755 FULLER AVE NE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495053780",
            "telephone_number": "616-363-1136",
            "fax_number": "616-363-4345"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FULLER AVENUE DENTAL ASSOCIATES",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-23",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "VISSCHER-WORST",
        "authorized_official_first_name": "SHANNON",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "616-363-1136",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "MI",
            "license": "16615",
            "primary": true
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "MI",
            "license": "10428",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Karen Fujii, M.S.W.
• Mary Deboer Fuler
• Keri Ann Fulkerson
• Full Circle Care, LLC
• Eric Fullen, LMSW
• Fuller Avenue Pharmacy
• Caleb Fuller
• Katherine S Fuller
• Nichole M Fuller
• Pamela Mary Fuller, RN

• General Practice Dentistry in Grand Rapids, MI
• Providers in Grand Rapids, MI by specialty
• General Practice Dentistry in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.