Provider Demographics
NPI:1730390063
Name:MCCULLOUGH, CHRISTINA MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:MARIE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15785 95TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4404
Mailing Address - Country:US
Mailing Address - Phone:763-420-5484
Mailing Address - Fax:
Practice Address - Street 1:15785 95TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4404
Practice Address - Country:US
Practice Address - Phone:763-420-5484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND123861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice