Provider Demographics
NPI:1477951614
Name:MCCULLOUGH, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 ORRCREST DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89506-8012
Mailing Address - Country:US
Mailing Address - Phone:661-565-5445
Mailing Address - Fax:
Practice Address - Street 1:371 S ROOP ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-4741
Practice Address - Country:US
Practice Address - Phone:775-882-0635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101470124Q00000X
CA20634124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist