Provider Demographics
NPI:1023171196
Name:MCCULLOUGH, SHAWN TIMOTHY (DDS)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:TIMOTHY
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:PO BOX 40
Mailing Address - Street 2:6041 MAIN STREET SUITE C
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056
Mailing Address - Country:US
Mailing Address - Phone:651-674-4811
Mailing Address - Fax:651-277-0411
Practice Address - Street 1:6041 MAIN STREET
Practice Address - Street 2:SUITE C
Practice Address - City:NORTH BRANCH
Practice Address - State:MN
Practice Address - Zip Code:55056
Practice Address - Country:US
Practice Address - Phone:651-674-4811
Practice Address - Fax:651-277-0411
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN011245122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist