Provider Demographics
NPI:1225131337
Name:MCCULLOUGH, DARRYAL DONERLSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:DARRYAL
Middle Name:DONERLSON
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:DARRYAL
Other - Middle Name:
Other - Last Name:DONERLSON-MCCULLOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2339 LAKE HARBIN RD
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-1905
Mailing Address - Country:US
Mailing Address - Phone:770-961-1222
Mailing Address - Fax:
Practice Address - Street 1:2339 LAKE HARBIN RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-1905
Practice Address - Country:US
Practice Address - Phone:770-961-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0107751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100273OtherAVESIS
GA9181250OtherDORAL
GA791518OtherUNITED CONCORDIA