Provider Demographics
NPI:1902368129
Name:STHANAM, MEGHANA
Entity Type:Individual
Prefix:
First Name:MEGHANA
Middle Name:
Last Name:STHANAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 21ST WAY S APT 1
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-5062
Mailing Address - Country:US
Mailing Address - Phone:205-999-1014
Mailing Address - Fax:
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-975-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190321951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice