Provider Demographics
NPI:1972145183
Name:DENTAL DREAM TEAM ASSOCIATES LLC YETTA MCCULLOM SOLE MBR
Entity Type:Organization
Organization Name:DENTAL DREAM TEAM ASSOCIATES LLC YETTA MCCULLOM SOLE MBR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:YETTA
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCCULLOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-488-9072
Mailing Address - Street 1:820 E 87TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-6256
Mailing Address - Country:US
Mailing Address - Phone:773-488-9072
Mailing Address - Fax:888-506-5697
Practice Address - Street 1:820 E 87TH ST STE 201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-6256
Practice Address - Country:US
Practice Address - Phone:773-488-9072
Practice Address - Fax:888-506-5697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty