Provider Demographics
NPI:1649472333
Name:AMERICAN FAMILY DENTAL CARE P.C
Entity type:Organization
Organization Name:AMERICAN FAMILY DENTAL CARE P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SETHURAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTHURAMASWAMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-547-1100
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:708-547-1149
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:708-547-1149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003292Medicaid