Provider Demographics
NPI:1932304904
Name:RAFIEIAN, SOUDABEH (DDS)
Entity Type:Individual
Prefix:
First Name:SOUDABEH
Middle Name:
Last Name:RAFIEIAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 N LINCOLN AVE
Mailing Address - Street 2:STE #C7 MID AMERICA DENTAL CENTER
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5480
Mailing Address - Country:US
Mailing Address - Phone:312-642-5107
Mailing Address - Fax:312-642-2958
Practice Address - Street 1:1920 N LINCOLN AVE
Practice Address - Street 2:STE #C7 MID AMERICA DENTAL CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-5480
Practice Address - Country:US
Practice Address - Phone:312-642-5107
Practice Address - Fax:312-642-2958
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice