Provider Demographics
NPI:1477531515
Name:REIZENSON, IGOR (DDS)
Entity Type:Individual
Prefix:DR
First Name:IGOR
Middle Name:
Last Name:REIZENSON
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 1:5053 BELAIR BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126
Mailing Address - Country:US
Mailing Address - Phone:716-316-5565
Mailing Address - Fax:
Practice Address - Street 1:1816 LAKEFIELD CT
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013
Practice Address - Country:US
Practice Address - Phone:770-860-8760
Practice Address - Fax:678-413-8144
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012633122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist