Provider Demographics
NPI:1750450128
Name:MUTHURAMASWAMI, SETHURAMA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SETHURAMA
Middle Name:
Last Name:MUTHURAMASWAMI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209.ST. CHARLES ROAD
Mailing Address - Street 2:
Mailing Address - City:BELLWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60104
Mailing Address - Country:US
Mailing Address - Phone:708-547-1100
Mailing Address - Fax:
Practice Address - Street 1:4209.ST. CHARLES ROAD
Practice Address - Street 2:
Practice Address - City:BELLWOOD
Practice Address - State:IL
Practice Address - Zip Code:60104
Practice Address - Country:US
Practice Address - Phone:708-547-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003092Medicaid