=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497894307
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW JAMES MCCULLOUGH D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
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 | 12 WHIPPOORWILL DR
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62246-2766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-664-3153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------