Provider Demographics
NPI:1376532671
Name:KLEBANOV, IGOR (DDS)
Entity Type:Individual
Prefix:DR
First Name:IGOR
Middle Name:
Last Name:KLEBANOV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7913 BAY PKWY
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-1959
Mailing Address - Country:US
Mailing Address - Phone:718-234-9014
Mailing Address - Fax:718-234-7771
Practice Address - Street 1:7913 BAY PKWY
Practice Address - Street 2:SUITE 1A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-1959
Practice Address - Country:US
Practice Address - Phone:718-234-9014
Practice Address - Fax:718-234-7771
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0455401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01526654Medicaid