Provider Demographics
NPI:1730228180
Name:LUBAEV, IGOR (DDS)
Entity type:Individual
Prefix:DR
First Name:IGOR
Middle Name:
Last Name:LUBAEV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8704 W GOLF RD
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-5610
Mailing Address - Country:US
Mailing Address - Phone:847-296-7070
Mailing Address - Fax:847-296-2438
Practice Address - Street 1:8704 W GOLF RD
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-5610
Practice Address - Country:US
Practice Address - Phone:847-296-7070
Practice Address - Fax:847-296-2438
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1002770Medicaid