Basic Information
| Provider Information | |||||||||
| NPI: | 1689744831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CULLUM | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1859 N LAKEWOOD DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086675565 | ||||||||
| FaxNumber: | 2087659633 | ||||||||
| Practice Location | |||||||||
| Address1: | 1859 N LAKEWOOD DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086675565 | ||||||||
| FaxNumber: | 2087659633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | D3149-0S | ID | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.