Provider Demographics
NPI:1417629817
Name:MCCULLOUGH, BRIAN TODD
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:TODD
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 BELLE OAK TRL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-8205
Mailing Address - Country:US
Mailing Address - Phone:166-254-9795
Mailing Address - Fax:
Practice Address - Street 1:706 BELLE OAK TRL
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-8205
Practice Address - Country:US
Practice Address - Phone:166-254-9795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4251-211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice