MEDICARE: ALEXANDRA MCCALLUM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	35409	TX
2	1223G0001X	General Practice Dentistry	019.032557	IL

General Provider Information

NPI Number	:	1801457791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRA MCCALLUM DDS

Provider Business Mailing Address
First Line	:	500 N LAKE SHORE DR APT 511
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-3994
Country	:	US
Telephone Number	:	682-429-7239
Fax Number	:

Provider Business Practice Location Address
First Line	:	413 W SAINT CHARLES RD
Second Line	:
City	:	VILLA PARK
State	:	IL
Zip	:	60181-2432
Country	:	US
Telephone Number	:	630-332-3811
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2019
Last Update Date	:	01/12/2022

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