Provider Demographics
NPI:1053819318
Name:DR. I DENTAL PC
Entity Type:Organization
Organization Name:DR. I DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:EMMANUIL
Authorized Official - Middle Name:
Authorized Official - Last Name:ILYAYEV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-517-8166
Mailing Address - Street 1:8610 GRAND AVE
Mailing Address - Street 2:1B
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373
Mailing Address - Country:US
Mailing Address - Phone:631-517-8166
Mailing Address - Fax:
Practice Address - Street 1:8610 GRAND AVE
Practice Address - Street 2:1B
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:631-517-8166
Practice Address - Fax:631-517-8166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058141261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental