Provider Demographics
NPI:1689744831
Name:CULLUM, DANIEL RAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:RAY
Last Name:CULLUM
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 1:1859 N LAKEWOOD DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2661
Mailing Address - Country:US
Mailing Address - Phone:208-667-5565
Mailing Address - Fax:208-765-9633
Practice Address - Street 1:1859 N LAKEWOOD DR
Practice Address - Street 2:SUITE 101
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2661
Practice Address - Country:US
Practice Address - Phone:208-667-5565
Practice Address - Fax:208-765-9633
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3149-0S1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1204250Medicare ID - Type Unspecified
IDT63980Medicare UPIN