Provider Demographics
NPI:1861177115
Name:MCCULLERS, ANDI JO
Entity type:Individual
Prefix:
First Name:ANDI
Middle Name:JO
Last Name:MCCULLERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-4043
Mailing Address - Country:US
Mailing Address - Phone:970-249-1543
Mailing Address - Fax:
Practice Address - Street 1:1127 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4043
Practice Address - Country:US
Practice Address - Phone:970-249-1543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002024855124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist