Provider Demographics
NPI:1528470838
Name:CULLY, IMOGENE (RDH)
Entity type:Individual
Prefix:
First Name:IMOGENE
Middle Name:
Last Name:CULLY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2770 PINEROCK DR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-2710
Mailing Address - Country:US
Mailing Address - Phone:541-324-4957
Mailing Address - Fax:
Practice Address - Street 1:2770 PINEROCK DR
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-2710
Practice Address - Country:US
Practice Address - Phone:541-324-4957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5279124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist