Healthcare Provider Details

I. General information

NPI: 1972649200
Provider Name (Legal Business Name): DRS. MCCULLOM P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E 87TH ST SUITE 201
CHICAGO IL
60619-6253
US

IV. Provider business mailing address

820 E 87TH ST SUITE 201
CHICAGO IL
60619-6253
US

V. Phone/Fax

Practice location:
  • Phone: 773-488-3738
  • Fax: 773-874-6575
Mailing address:
  • Phone: 773-488-3738
  • Fax: 773-874-6575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. YETTA G MCCULLOM
Title or Position: VP AND CHEIF FINANICAL OFFICER
Credential: DDS
Phone: 773-488-3738