MEDICARE: MICHAEL R MCCULLOCH DDS PC

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	122300000X	Dentist	11730	TX

General Provider Information

NPI Number	:	1619045044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL R MCCULLOCH DDS PC

Provider Business Mailing Address
First Line	:	23020 HIGHLAND KNOLLS #B
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-8257
Country	:	US
Telephone Number	:	281-693-6427
Fax Number	:	281-693-4258

Provider Business Practice Location Address
First Line	:	23020 HIGHLAND KNOLLS #B
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-8257
Country	:	US
Telephone Number	:	281-693-6427
Fax Number	:	281-693-4258

Authorized Official
Title or Position	:	PRESIDENT OWNER
Name	:	MICHAEL RAY MCCULLOCH
Credential	:	DDS
Telephone Number	:	281-693-6427

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	08/22/2020

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