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Provider Information for 1780033225



LARISA ILYUTOVICH

Gender: MALE

Individual NPI: 1780033225

Calendar Last Updated: 2016-06-06

Details

Name Value
NPI 1780033225
Enumeration Date 2016-06-06
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 301 BRIDGE PLZ N SUITE 2
FORT LEE, NJ 07024-5059
United States

Phone: 201-346-4660 | Fax: 201-346-1116
View Map External Link
Primary Practice Address 301 BRIDGE PLZ N SUITE 2
FORT LEE, NJ 07024-5059
United States

Phone: 201-346-4660 | Fax: 201-346-1116
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
MEDICAID NJ 8797404
Taxonomy
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223G0001X - Dentist General Practice NJ DI020299