Provider Demographics
NPI:1982760393
Name:MCCULLOUGH, GREGORY SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
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 1:401 NW 18TH ST
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-4260
Mailing Address - Country:US
Mailing Address - Phone:515-964-0081
Mailing Address - Fax:515-964-2902
Practice Address - Street 1:401 NW 18TH ST
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-4260
Practice Address - Country:US
Practice Address - Phone:515-964-0081
Practice Address - Fax:515-964-2902
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA77981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice