MEDICARE: IBBI DENTAL CLINIC/IGOR BOTVINNIK

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	019025138	IL

General Provider Information

NPI Number	:	1356593206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IBBI DENTAL CLINIC/IGOR BOTVINNIK

Provider Business Mailing Address
First Line	:	1753 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-5009
Country	:	US
Telephone Number	:	312-491-0033
Fax Number	:

Provider Business Practice Location Address
First Line	:	1753 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-5009
Country	:	US
Telephone Number	:	312-491-0033
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. IGOT BOTVINNIK
Credential	:	D.D.S.
Telephone Number	:	847-583-0033

Provider Enumeration Date	:	10/22/2008
Last Update Date	:	10/22/2008

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