Provider Demographics
NPI:1386020550
Name:DR. DANIEL R CULLUM PA
Entity Type:Organization
Organization Name:DR. DANIEL R CULLUM PA
Other - Org Name:IMPLANTS NORTHWEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CULLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-667-5565
Mailing Address - Street 1:1859 N LAKEWOOD DR
Mailing Address - Street 2:STE 101
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2661
Mailing Address - Country:US
Mailing Address - Phone:208-667-5565
Mailing Address - Fax:208-765-9633
Practice Address - Street 1:1859 N LAKEWOOD DR
Practice Address - Street 2:STE 101
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2661
Practice Address - Country:US
Practice Address - Phone:208-667-5565
Practice Address - Fax:208-765-9633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3149-OS1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD-3149-OSOtherSTATE LICENSE