Provider Demographics
NPI:1265443477
Name:MARIMUTHU, SUBBASHINI (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUBBASHINI
Middle Name:
Last Name:MARIMUTHU
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 1:1155 N MAIN ST
Mailing Address - Street 2:STE. A
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-3508
Mailing Address - Country:US
Mailing Address - Phone:630-545-1116
Mailing Address - Fax:630-545-1117
Practice Address - Street 1:1155 N MAIN ST
Practice Address - Street 2:STE. A
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-3508
Practice Address - Country:US
Practice Address - Phone:630-545-1116
Practice Address - Fax:630-545-1117
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190260281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
331048209OtherIRS INDIVIDUAL TAX PAYER
331048209OtherIRS INDIVIDUAL TAX PAYER