Forrest Wane Fullenkamp, DDS
Individual provider Active NPI Dentist · Decatur, IN
NPI 1730733007 · NPPES record last updated Apr 29, 2024
Key facts
- NPI
- 1730733007
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 12013196A (IN)
- Practice address
- 1020 Southampton Dr
Decatur, IN 46733-1049 - Phone
- (260) 724-8410
- NPI assigned
- Jul 25, 2019
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 12013196A | IN | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Decatur Family Dentistry 2.0 | Current |
Accepting new patients | |
| Decatur Family Dentistry of Adams County LLC | Current |
Accepting new patients |
Locations
1020 Southampton Dr
Decatur, IN 46733
Phone (260) 724-8410
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 12013196A | IN | Yes |
Addresses
Primary practice location
1020 Southampton Dr
Decatur, IN 46733-1049
Mailing address
1020 Southampton Dr
Decatur, IN 46733-1049
Phone (260) 724-8410
Other practice location 1
Fort Bragg Dentac
Fort Bragg, NC 28310-0001
Phone (260) 223-7533
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 12013196A | Other | IN | INDIANA PROFESSIONAL LICENSING AGENCY |
Other providers in Decatur, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 29, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.