Provider Demographics
NPI:1013188242
Name:ILYABAYEV, IGOR (DDS)
Entity Type:Individual
Prefix:DR
First Name:IGOR
Middle Name:
Last Name:ILYABAYEV
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 1:139 N CENTRAL AVE
Mailing Address - Street 2:SUITE#3
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-3856
Mailing Address - Country:US
Mailing Address - Phone:516-887-0020
Mailing Address - Fax:516-887-0080
Practice Address - Street 1:139 N CENTRAL AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-3856
Practice Address - Country:US
Practice Address - Phone:516-887-0020
Practice Address - Fax:516-887-0080
Is Sole Proprietor?:No
Enumeration Date:2008-03-15
Last Update Date:2015-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052814122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03168361Medicaid