Provider Demographics
NPI:1407166655
Name:WJM DENTAL INC
Entity Type:Organization
Organization Name:WJM DENTAL INC
Other - Org Name:WILLIE MCLULLUM DDS - CHILDREN'S DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MCCULLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-474-0606
Mailing Address - Street 1:4002 SOUTH M STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418
Mailing Address - Country:US
Mailing Address - Phone:253-474-0606
Mailing Address - Fax:
Practice Address - Street 1:4002 SOUTH M STREET
Practice Address - Street 2:SUITE A
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418
Practice Address - Country:US
Practice Address - Phone:253-474-0606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA63261223G0001X
WA89201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5050273Medicaid