Provider Demographics
NPI:1215388608
Name:GANZMAN, IRINA VICTORIA (DMD)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:VICTORIA
Last Name:GANZMAN
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 1:2400 RAVINE WAY STE 400
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-7615
Mailing Address - Country:US
Mailing Address - Phone:847-998-5100
Mailing Address - Fax:
Practice Address - Street 1:2400 RAVINE WAY STE 400
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7615
Practice Address - Country:US
Practice Address - Phone:847-998-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.030742122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist