Provider Demographics
NPI:1689687451
Name:MCCULLOCH, ROBERT WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:MCCULLOCH
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 1:226 S 94TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-9796
Mailing Address - Country:US
Mailing Address - Phone:509-457-5914
Mailing Address - Fax:
Practice Address - Street 1:226 S 94TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-9796
Practice Address - Country:US
Practice Address - Phone:509-457-5914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00004376122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist