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General NPI Number Information
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NPI Number | 1740326313
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Entity Type | Organization
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Legal Business Name | IRINA BOLOTNIKOV DDS PC
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Dates
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Enumeration Date | 01/30/2007
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Last Update Date | 06/18/2008
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Provider Practice Location Address
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Address Line | 7963 GOLD ROAD
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City | MORTON GROVE
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State | IL
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Zip | 60053
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Country | US
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Telephone | 847-583-0033
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Fax | 847-583-0013
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Provider Business Mailing Address
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Address Line | 7963 GOLD ROAD
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City | MORTON GROVE
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State | IL
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Zip | 60053
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Country | US
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Telephone | 847-583-0033
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Fax | 847-583-0013
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Authorized Official
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Title or Position | DENTIST PRESIDENT
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Name | IRINA BOLOTNIKOV
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Credential | DDS
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Telephone | 847-583-0033
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019029871
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License Number State | IL
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