Provider Demographics
NPI:1629115761
Name:BABICHENKO, GENNADY S (LD)
Entity Type:Individual
Prefix:MR
First Name:GENNADY
Middle Name:S
Last Name:BABICHENKO
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10480 W GARVERDALE CT STE 804B
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5477
Mailing Address - Country:US
Mailing Address - Phone:208-376-6613
Mailing Address - Fax:
Practice Address - Street 1:10480 W GARVERDALE CT STE 804B
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5477
Practice Address - Country:US
Practice Address - Phone:208-376-6613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD44122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist