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General NPI Number Information
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NPI Number | 1972145183
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Entity Type | Organization
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Legal Business Name | DENTAL DREAM TEAM ASSOCIATES LLC YETTA MCCULLOM SOLE MBR
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Dates
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Enumeration Date | 10/09/2019
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Last Update Date | 10/09/2019
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Provider Practice Location Address
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Address Line | 820 E 87TH ST STE 201
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City | CHICAGO
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State | IL
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Zip | 60619-6256
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Country | US
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Telephone | 773-488-9072
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Fax | 888-506-5697
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Provider Business Mailing Address
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Address Line | 820 E 87TH ST STE 201
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City | CHICAGO
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State | IL
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Zip | 60619-6256
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Country | US
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Telephone | 773-488-9072
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Fax | 888-506-5697
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Authorized Official
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Title or Position | MANAGER SOLE MEMBER
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Name | YETTA G MCCULLOM
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Credential | DDS
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Telephone | 773-488-9072
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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