Provider Demographics
NPI:1356593206
Name:IBBI DENTAL CLINIC/IGOR BOTVINNIK
Entity type:Organization
Organization Name:IBBI DENTAL CLINIC/IGOR BOTVINNIK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IGOT
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTVINNIK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-583-0033
Mailing Address - Street 1:1753 W CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5009
Mailing Address - Country:US
Mailing Address - Phone:312-491-0033
Mailing Address - Fax:
Practice Address - Street 1:1753 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-5009
Practice Address - Country:US
Practice Address - Phone:312-491-0033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190251381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty