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General NPI Number Information
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NPI Number | 1104093814
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Entity Type | Organization
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Legal Business Name | IK DENTAL
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Dates
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Enumeration Date | 05/12/2008
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 4405 BROADWAY
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City | NEW YORK
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State | NY
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Zip | 10040-4014
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Country | US
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Telephone | 212-568-1500
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Fax | 855-201-3647
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Provider Business Mailing Address
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Address Line | 4405 BROADWAY
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City | NEW YORK
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State | NY
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Zip | 10040-4014
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Country | US
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Telephone | 212-568-1500
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Fax | 855-201-3647
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Authorized Official
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Title or Position | AUTHERIZED OFFICIAL
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Name | DR. IGOR KLEBANOV
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Credential | DDS
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Telephone | 212-568-1500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 045540
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 045540
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License Number State | NY
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