Provider Demographics
NPI:1700550290
Name:SAMEENABANO, FNU
Entity Type:Individual
Prefix:
First Name:FNU
Middle Name:
Last Name:SAMEENABANO
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 1:903 S ASHLAND AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4094
Mailing Address - Country:US
Mailing Address - Phone:630-440-1314
Mailing Address - Fax:
Practice Address - Street 1:3435 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3217
Practice Address - Country:US
Practice Address - Phone:773-588-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019033317122300000X
IL019.033317122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist