Provider Demographics
NPI:1245713197
Name:MCCULLOUGH, BRANDON (DDS)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
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 1:210 S. MONTCLAIR ST
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309
Mailing Address - Country:US
Mailing Address - Phone:210-240-6243
Mailing Address - Fax:
Practice Address - Street 1:210 S MONTCLAIR ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-3164
Practice Address - Country:US
Practice Address - Phone:661-397-0665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103193122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist