M. Camille Fuller, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

016112 Issued in MO

Practice address

808 W 58TH St
Los Angeles, CA 90037-3632

Phone

(323) 541-1600

Fax

(323) 541-1499

NPI assigned

Jul 27, 2007

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

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

{
    "created_epoch": "1185494400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1493683200000",
    "number": "1902096720",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "109 CALIFORNIA ST",
            "address_2": "P.O. BOX 577",
            "city": "CARTERVILLE",
            "state": "IL",
            "postal_code": "629181923",
            "telephone_number": "618-985-8221",
            "fax_number": "618-985-6860"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "808 W 58TH ST",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900373632",
            "telephone_number": "323-541-1600",
            "fax_number": "323-541-1499"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FULLER",
        "first_name": "M. CAMILLE",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-07-27",
        "last_updated": "2017-05-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MO",
            "license": "016112",
            "primary": true
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "IL",
            "license": "319011093",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• David Lee Fuller II, M.D.
• Deborah Fuller, MA
• Jack G. Fuller, PA-C
• Jennifer Elizabeth Fuller, PT
• Laura Marie Fuller, MFT INTERN
• Myesha Fuller, CMT
• Perry Fuller
• Samantha Elizeth Fuller
• Solomon Fuller
• Fullfill, Inc.

• General Practice Dentistry in Los Angeles, CA
• Providers in Los Angeles, CA by specialty
• General Practice Dentistry in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 2, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.