Provider Demographics
NPI:1497782650
Name:KULL, STANLEY L (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:L
Last Name:KULL
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BURNS
Mailing Address - State:OR
Mailing Address - Zip Code:97720-1408
Mailing Address - Country:US
Mailing Address - Phone:541-573-7778
Mailing Address - Fax:541-573-1191
Practice Address - Street 1:555 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BURNS
Practice Address - State:OR
Practice Address - Zip Code:97720-1408
Practice Address - Country:US
Practice Address - Phone:541-573-7778
Practice Address - Fax:541-573-1191
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OOOONGCFFMedicare ID - Type Unspecified
T67823Medicare UPIN