Healthcare Provider Details

I. General information

NPI: 1265111462
Provider Name (Legal Business Name): JACOB H MCCULLOUGH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JACOB H MCCULLOUGH DR

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 WISCONSIN AVE BETHESDA MD 20889
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

WALTER REED NATIONAL MILITARY CTR 8901 WISCONSIN AVE
BETHESDA MD
20889-0001
US

V. Phone/Fax

Practice location:
  • Phone: 206-697-1751
  • Fax:
Mailing address:
  • Phone: 301-295-0064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13453484-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: