Provider Demographics
NPI:1902941263
Name:IBBI DENTAL CLINIC PC
Entity Type:Organization
Organization Name:IBBI DENTAL CLINIC PC
Other - Org Name:IGOR BOTVINNIK DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTVINNIK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-583-0033
Mailing Address - Street 1:7963 GOLF ROAD
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053
Mailing Address - Country:US
Mailing Address - Phone:847-583-0033
Mailing Address - Fax:847-583-0013
Practice Address - Street 1:7963 GOLF ROAD
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053
Practice Address - Country:US
Practice Address - Phone:847-583-0033
Practice Address - Fax:847-583-0013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004642Medicaid