=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245379171
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATTHEW J MCCULLOUGH DMD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 05/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 E CITY ROUTE 40
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62246-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-664-1483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 E CITY ROUTE 40
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62246-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-664-1483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MATTHEW JAMES MCCULLOUGH
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 618-664-1483
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | 019-025298
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019025298
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------