Provider Demographics
NPI:1205996428
Name:MCCULLOUGH, RAY MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:MICHAEL
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 1:29743 CHAPEL PARK DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-4491
Mailing Address - Country:US
Mailing Address - Phone:813-849-3508
Mailing Address - Fax:
Practice Address - Street 1:7551 FOREST OAKS BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-2437
Practice Address - Country:US
Practice Address - Phone:352-518-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN174341223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice