Provider Demographics
NPI:1164507471
Name:RAZDOLSKY, YAN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:YAN
Middle Name:M
Last Name:RAZDOLSKY
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 1:227 BRAMPTON LN
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-4706
Mailing Address - Country:US
Mailing Address - Phone:847-980-7836
Mailing Address - Fax:
Practice Address - Street 1:600 W LAKE COOK RD
Practice Address - Street 2:SUITE 150
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-2089
Practice Address - Country:US
Practice Address - Phone:847-215-7554
Practice Address - Fax:847-215-7563
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics