=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730356148
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCCULLOUGH FAMILY DENTISTRY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2008
-----------------------------------------------------
Last Update Date | 05/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1630 SW WHITE BIRCH CIR
-----------------------------------------------------
City | ANKENY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50023-7213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-965-4470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1630 SW WHITE BIRCH CIR
-----------------------------------------------------
City | ANKENY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50023-7213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-965-4470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MATTHEW MCCULLOUGH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 515-965-4470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 7932
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------