Yetta G McCullom, DDS, MA

Primary specialty

PeriodonticsTaxonomy code 1223P0300X

License

021001516 Issued in IL

Practice address

820 E 87TH St
Ste 201
Chicago, IL 60619-6253

Phone

(773) 488-3738

Fax

(773) 874-6575

NPI assigned

Sep 22, 2008

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Master of Arts

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Dental Dream Team Associates LLC Yetta McCullom Sole MBR

  • Periodontics
  • Chicago, IL
  • NPI 1972145183
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1222041600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1222128000000",
    "number": "1285884791",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "820 E 87TH ST",
            "address_2": "STE 201",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606196253",
            "telephone_number": "773-488-3738",
            "fax_number": "773-874-6575"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "820 E 87TH ST",
            "address_2": "STE 201",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606196253",
            "telephone_number": "773-488-3738",
            "fax_number": "773-874-6575"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MCCULLOM",
        "first_name": "YETTA",
        "middle_name": "G",
        "credential": "DDS, MA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2008-09-22",
        "last_updated": "2008-09-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "",
            "desc": "Dentist, Periodontics",
            "state": "IL",
            "license": "021001516",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Adam J McCue, AGACNP-BC
• Cassidy Shay McCue
• Doris Jean McCulley, M.D.,M.B.A.
• Cornell McCullom III, D.D.S., M.D.
• Noelle Galiber McCullom, DDS
• Imari C McCullough
• Kristin M McCullough, DDS
• Lindsay McCullough, M.D.
• Megan McCullough
• Michelle Ann McCullough, L.C.S.W.

• Periodontics in Chicago, IL
• Providers in Chicago, IL by specialty
• Periodontics in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 23, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.