MEDICARE: IGOR KLEBANOV DDS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	045540	NY

General Provider Information

NPI Number	:	1326322389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IGOR KLEBANOV DDS PC

Provider Business Mailing Address
First Line	:	7913 BAY PKWY
Second Line	:	#A-1
City	:	BROOKLYN
State	:	NY
Zip	:	11214-1959
Country	:	US
Telephone Number	:	718-234-9014
Fax Number	:	718-234-7771

Provider Business Practice Location Address
First Line	:	7913 BAY PKWY
Second Line	:	#A-1
City	:	BROOKLYN
State	:	NY
Zip	:	11214-1959
Country	:	US
Telephone Number	:	718-234-9014
Fax Number	:	718-234-7771

Authorized Official
Title or Position	:	DDS
Name	:	DR. IGOR KLEBANOV
Credential	:
Telephone Number	:	718-234-9014

Provider Enumeration Date	:	10/07/2011
Last Update Date	:	10/07/2011

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