Provider Demographics
NPI:1497179253
Name:MCCULLOUGH, JEFFREY J (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:J
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4281 KATELLA AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3502
Mailing Address - Country:US
Mailing Address - Phone:714-484-8700
Mailing Address - Fax:
Practice Address - Street 1:4281 KATELLA AVE STE 112
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720
Practice Address - Country:US
Practice Address - Phone:714-484-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA622891223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics