Healthcare Provider Details

I. General information

NPI: 1548549439
Provider Name (Legal Business Name): IGOR RISTEVSKI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 E. 84TH DRIVE SUITE 106
MERRILLVILLE IN
46410-6465
US

IV. Provider business mailing address

233 E. 84TH DRIVE SUITE 106
MERRILLVILLE IN
46410-6465
US

V. Phone/Fax

Practice location:
  • Phone: 219-736-2309
  • Fax: 219-736-2328
Mailing address:
  • Phone: 219-736-2309
  • Fax: 219-736-2328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12011692A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: