Provider Demographics
NPI:1801457791
Name:MCCALLUM, ALEXANDRA (DDS)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:MCCALLUM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N LAKE SHORE DR APT 511
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3994
Mailing Address - Country:US
Mailing Address - Phone:682-429-7239
Mailing Address - Fax:
Practice Address - Street 1:413 W SAINT CHARLES RD
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-2432
Practice Address - Country:US
Practice Address - Phone:630-332-3811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-22
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX354091223G0001X
IL019.0325571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice