Provider Demographics
NPI:1215218649
Name:KAZBANOV, IRINA (DMD)
Entity Type:Individual
Prefix:DR
First Name:IRINA
Middle Name:
Last Name:KAZBANOV
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 MYRTLE AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1411
Mailing Address - Country:US
Mailing Address - Phone:917-532-0226
Mailing Address - Fax:
Practice Address - Street 1:93 MYRTLE AVE
Practice Address - Street 2:APT 2
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1411
Practice Address - Country:US
Practice Address - Phone:917-532-0226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056302-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist