Provider Demographics
NPI:1730672296
Name:JEFFREY J. MCCULLOUGH DMD, MS, INC.
Entity Type:Organization
Organization Name:JEFFREY J. MCCULLOUGH DMD, MS, INC.
Other - Org Name:LOS ALAMITOS PERIODONTICS & DENTAL IMPLANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:717-877-8268
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:90720-3502
Practice Address - Country:US
Practice Address - Phone:714-484-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-10
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA622891223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty