Provider Demographics
NPI:1285884791
Name:MCCULLOM, YETTA G (DDS, MA)
Entity type:Individual
Prefix:
First Name:YETTA
Middle Name:G
Last Name:MCCULLOM
Suffix:
Gender:F
Credentials:DDS, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 E 87TH ST
Mailing Address - Street 2:STE 201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-6253
Mailing Address - Country:US
Mailing Address - Phone:773-488-3738
Mailing Address - Fax:773-874-6575
Practice Address - Street 1:820 E 87TH ST
Practice Address - Street 2:STE 201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-6253
Practice Address - Country:US
Practice Address - Phone:773-488-3738
Practice Address - Fax:773-874-6575
Is Sole Proprietor?:No
Enumeration Date:2008-09-22
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210015161223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics