Provider Demographics
NPI:1386859528
Name:ROGER S. CULLEN DENTAL CORP.
Entity Type:Organization
Organization Name:ROGER S. CULLEN DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:S
Authorized Official - Last Name:CULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-586-8530
Mailing Address - Street 1:25270 MARGUERITE PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-2910
Mailing Address - Country:US
Mailing Address - Phone:949-586-8530
Mailing Address - Fax:949-951-1407
Practice Address - Street 1:25270 MARGUERITE PKWY STE C
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-2910
Practice Address - Country:US
Practice Address - Phone:949-586-8530
Practice Address - Fax:949-951-1407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24220122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty