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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
Taxonomy
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223G0001X - Dentist General Practice NJ DI020299
Other Identifiers
Issuer State Number
MEDICAID NJ 8797404
Endpoint Information
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location