Provider Demographics
NPI:1619124807
Name:MCCULLOM, CORNELL III (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:CORNELL
Middle Name:
Last Name:MCCULLOM
Suffix:III
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210014881223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery