Provider Demographics
NPI:1144424292
Name:YUSUPOV, AZARIY (DDS)
Entity Type:Individual
Prefix:DR
First Name:AZARIY
Middle Name:
Last Name:YUSUPOV
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 1:63-60 102ND STREET
Mailing Address - Street 2:#D18
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374
Mailing Address - Country:US
Mailing Address - Phone:718-897-3940
Mailing Address - Fax:
Practice Address - Street 1:349 E NORTHFIELD RD
Practice Address - Street 2:SUITE 207
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-4802
Practice Address - Country:US
Practice Address - Phone:973-535-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDIO2344900122300000X
NY0528601223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist