MEDICARE: DR. EDWARD J MCCULLOCH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223D0001X	Public Health Dentistry	104717	CO

General Provider Information

NPI Number	:	1427058445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD J MCCULLOCH DDS

Provider Business Mailing Address
First Line	:	3585 VAN TEYLINGEN DR
Second Line	:	STE F
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-4875
Country	:	US
Telephone Number	:	719-597-7111
Fax Number	:	719-572-0177

Provider Business Practice Location Address
First Line	:	3585 VAN TEYLINGEN DR
Second Line	:	STE F
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-4875
Country	:	US
Telephone Number	:	719-597-7111
Fax Number	:	719-572-0177

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2005
Last Update Date	:	07/08/2007

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