Provider Demographics
NPI:1164926788
Name:MCCULLOUGH, ROBERT LYLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LYLE
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27440 SW VANDERSCHUERE RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-9439
Mailing Address - Country:US
Mailing Address - Phone:503-964-8909
Mailing Address - Fax:
Practice Address - Street 1:11820 SW KING JAMES PL STE 20
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-2481
Practice Address - Country:US
Practice Address - Phone:503-968-2901
Practice Address - Fax:503-406-4988
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD111141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice