Provider Demographics
NPI:1447382353
Name:MCCULLOUGH, THOMAS C (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
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 1:3226 132ND ST SW
Mailing Address - Street 2:STE 106
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012
Mailing Address - Country:US
Mailing Address - Phone:425-379-2848
Mailing Address - Fax:425-338-4651
Practice Address - Street 1:3226 132ND ST SW
Practice Address - Street 2:STE 106
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012
Practice Address - Country:US
Practice Address - Phone:425-379-2848
Practice Address - Fax:425-338-4651
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA47701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5398904Medicaid