Provider Demographics
NPI:1104093814
Name:IK DENTAL
Entity type:Organization
Organization Name:IK DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHERIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEBANOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-568-1500
Mailing Address - Street 1:4405 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-4014
Mailing Address - Country:US
Mailing Address - Phone:212-568-1500
Mailing Address - Fax:855-201-3647
Practice Address - Street 1:4405 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-4014
Practice Address - Country:US
Practice Address - Phone:212-568-1500
Practice Address - Fax:855-201-3647
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045540122300000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No122300000XDental ProvidersDentistGroup - Single Specialty