Provider Demographics
NPI:1639662372
Name:CULLEN, DEIDRE R (OD)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:R
Last Name:CULLEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 LACONIA RD STE 132
Mailing Address - Street 2:
Mailing Address - City:TILTON
Mailing Address - State:NH
Mailing Address - Zip Code:03276-5236
Mailing Address - Country:US
Mailing Address - Phone:603-729-0237
Mailing Address - Fax:603-729-0327
Practice Address - Street 1:120 LACONIA RD STE 132
Practice Address - Street 2:
Practice Address - City:TILTON
Practice Address - State:NH
Practice Address - Zip Code:03276-5236
Practice Address - Country:US
Practice Address - Phone:603-729-0237
Practice Address - Fax:603-729-0327
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0969152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist