Provider Demographics
NPI:1518129667
Name:MCCULLOUGH, KRISTIN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:M
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KRISTIN
Other - Middle Name:M
Other - Last Name:MCCULLOUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2733 W POTOMAC AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2836
Mailing Address - Country:US
Mailing Address - Phone:312-399-8749
Mailing Address - Fax:
Practice Address - Street 1:2733 W POTOMAC AVE
Practice Address - Street 2:UNIT 2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2836
Practice Address - Country:US
Practice Address - Phone:312-399-8749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.026987122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist