Provider Demographics
NPI:1992709877
Name:MCCULLAR, BRUCE H (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:H
Last Name:MCCULLAR
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 1:805 ESTATE PL
Mailing Address - Street 2:STE 2
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-0647
Mailing Address - Country:US
Mailing Address - Phone:901-682-9713
Mailing Address - Fax:901-685-9633
Practice Address - Street 1:805 ESTATE PL
Practice Address - Street 2:STE 2
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-0647
Practice Address - Country:US
Practice Address - Phone:901-682-9713
Practice Address - Fax:901-685-9633
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
TN35851223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT74376Medicare UPIN
TN3224944Medicare ID - Type Unspecified