MEDICARE: DR. IGOR REIZENSON DDS

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	122300000X	Dentist	DN012633	GA

General Provider Information

NPI Number	:	1477531515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IGOR REIZENSON DDS

Provider Business Mailing Address
First Line	:	5053 BELAIR BLUFF CT
Second Line	:
City	:	MABLETON
State	:	GA
Zip	:	30126
Country	:	US
Telephone Number	:	716-316-5565
Fax Number	:

Provider Business Practice Location Address
First Line	:	1816 LAKEFIELD CT
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30013
Country	:	US
Telephone Number	:	770-860-8760
Fax Number	:	678-413-8144

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2006
Last Update Date	:	07/08/2007

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