Provider Demographics
NPI:1316208226
Name:BABENKOV, IGOR
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:BABENKOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 PAIZANO CT
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3978
Mailing Address - Country:US
Mailing Address - Phone:916-517-6578
Mailing Address - Fax:
Practice Address - Street 1:125 PAIZANO CT
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3978
Practice Address - Country:US
Practice Address - Phone:916-517-6578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA613301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice