Provider Demographics
NPI:1861830622
Name:MCCULLOUGH, MICHAEL SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:MCCULLOUGH
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 1:11400 PALM DR
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-3167
Mailing Address - Country:US
Mailing Address - Phone:760-329-2227
Mailing Address - Fax:
Practice Address - Street 1:11400 PALM DR
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-3167
Practice Address - Country:US
Practice Address - Phone:760-329-2227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40855122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist