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General NPI Number Information
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NPI Number | 1730672296
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Entity Type | Organization
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Legal Business Name | JEFFREY J. MCCULLOUGH DMD, MS, INC.
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Dates
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Enumeration Date | 06/10/2018
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Last Update Date | 06/10/2018
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Provider Practice Location Address
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Address Line | 4281 KATELLA AVE STE 112
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City | LOS ALAMITOS
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State | CA
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Zip | 90720-3502
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Country | US
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Telephone | 714-484-8700
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Fax |
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Provider Business Mailing Address
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Address Line | 4281 KATELLA AVE STE 112
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City | LOS ALAMITOS
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State | CA
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Zip | 90720-3502
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Country | US
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Telephone | 714-484-8700
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JEFFREY J MCCULLOUGH
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Credential | DMD, MS
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Telephone | 717-877-8268
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 62289
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License Number State | CA
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