Provider Demographics
NPI:1417527995
Name:MCCULLOUGH, AUSTIN (DDS)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 E CARTER ST APT 6
Mailing Address - Street 2:DOWNSTAIRS UNDER THE PORCH
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5371
Mailing Address - Country:US
Mailing Address - Phone:218-849-4128
Mailing Address - Fax:
Practice Address - Street 1:921 S 8TH AVE STOP 8088
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0002
Practice Address - Country:US
Practice Address - Phone:208-282-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5283122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist