Provider Demographics
NPI:1285473181
Name:IBRAGIMOV, IGOR (DMD)
Entity type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:IBRAGIMOV
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12720 KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473
Mailing Address - Country:US
Mailing Address - Phone:573-596-1470
Mailing Address - Fax:
Practice Address - Street 1:12720 KANSAS AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473
Practice Address - Country:US
Practice Address - Phone:573-596-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT00000000000000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist