Provider Demographics
NPI:1265111462
Name:MCCULLOUGH, JACOB H (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:H
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JACOB
Other - Middle Name:H
Other - Last Name:MCCULLOUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DR
Mailing Address - Street 1:200 MERCY CIRCLE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MERCY CIR
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-1288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-14
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13453484-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice