Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 3585 | TN |
NPI | 1992709877 |
---|---|
Provider Name | Dr. Bruce H Mccullar |
First Address | Memphis, TN 38120-0647 |
Second Address | Memphis, TN 38120-0647 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T74376 | (02) | TN |