MEDICARE: DR. WILLIE JAMES MCCULLUM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6326	WA

General Provider Information

NPI Number	:	1083622971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIE JAMES MCCULLUM DDS

Provider Business Mailing Address
First Line	:	4002 SOUTH 'M' STREET
Second Line	:	SUITE A
City	:	TACOMA
State	:	WA
Zip	:	98418
Country	:	US
Telephone Number	:	253-474-0606
Fax Number	:	253-476-3901

Provider Business Practice Location Address
First Line	:	4002 SOUTH 'M' STREET
Second Line	:	SUITE A
City	:	TACOMA
State	:	WA
Zip	:	98418
Country	:	US
Telephone Number	:	253-474-0606
Fax Number	:	253-476-3901

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	03/03/2010

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