1609954064 NPI number — LARISA ILYUTOVICH DDS PC

Table of content: (NPI 1609954064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609954064 NPI number — LARISA ILYUTOVICH DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARISA ILYUTOVICH DDS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609954064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 BRIDGE PLAZA NORTH
Provider Second Line Business Mailing Address:
2ND FLR
Provider Business Mailing Address City Name:
FORT LEE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-346-4660
Provider Business Mailing Address Fax Number:
201-346-1116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 BRIDGE PLAZA NORTH
Provider Second Line Business Practice Location Address:
2ND FLR
Provider Business Practice Location Address City Name:
FORT LEE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-346-4660
Provider Business Practice Location Address Fax Number:
201-346-1116
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ILYUTOVICH
Authorized Official First Name:
LARISA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
201-346-4660

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DI020299 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8797404 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com