=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043376320
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN L. CULLEN D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2359 S 22ND DR SUITE 1
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-8871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-329-9565
-----------------------------------------------------
Fax | 928-783-0669
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2359 S 22ND DR SUITE 1
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-8871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-329-9565
-----------------------------------------------------
Fax | 928-783-0669
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | AZ4111
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------