Provider Demographics
NPI:1023363603
Name:JOVICIC, IRENE (DMD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:JOVICIC
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:IRINA
Other - Middle Name:
Other - Last Name:PISAREVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2611 ST ALBANS CIR
Mailing Address - Street 2:APT 205
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-4818
Mailing Address - Country:US
Mailing Address - Phone:847-452-3357
Mailing Address - Fax:
Practice Address - Street 1:55 S MAIN ST
Practice Address - Street 2:SUITE 241
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-5372
Practice Address - Country:US
Practice Address - Phone:630-848-2010
Practice Address - Fax:630-848-2011
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190291401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice