Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 2016021116 | MO |
NPI | 1053843185 |
---|---|
Provider Name | Crystal Mccullough |
First Address | Clinton, MO 64735-8804 |
Second Address | Clinton, MO 64735-8804 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2017 |
Last Update Date | 15/05/2018 |