Provider Demographics
NPI:1053843185
Name:MCCULLOUGH, CRYSTAL (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:1800 COMMUNITY
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-8804
Practice Address - Country:US
Practice Address - Phone:888-403-1071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016021116124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist