Provider Demographics
NPI:1871687624
Name:DONERLSON-MCCULLOUGH DENTAL CENTER
Entity type:Organization
Organization Name:DONERLSON-MCCULLOUGH DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRYAL
Authorized Official - Middle Name:DONERLSON
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-961-1222
Mailing Address - Street 1:2339 LAKE HARBIN RD
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260
Mailing Address - Country:US
Mailing Address - Phone:770-961-1222
Mailing Address - Fax:
Practice Address - Street 1:2339 LAKE HARBIN RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260
Practice Address - Country:US
Practice Address - Phone:770-961-1222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA107751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA39154OtherAVESIS
GA1312005OtherUNITED CONCORDIA
GA167133OtherDORAL DENTAL