Provider Demographics
NPI:1003047929
Name:ETMINAN, SODABEH (DMD)
Entity Type:Individual
Prefix:DR
First Name:SODABEH
Middle Name:
Last Name:ETMINAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 S WOOD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1202
Mailing Address - Country:US
Mailing Address - Phone:312-413-1789
Mailing Address - Fax:
Practice Address - Street 1:7131 S JEFFERY BLVD STE A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-2176
Practice Address - Country:US
Practice Address - Phone:773-256-0526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0279791223G0001X
IN12012268A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Yes1223G0001XDental ProvidersDentistGeneral Practice