Provider Demographics
NPI:1164599494
Name:GAVRILOV, LILIA
Entity Type:Individual
Prefix:DR
First Name:LILIA
Middle Name:
Last Name:GAVRILOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MEETING STREET
Mailing Address - Street 2:
Mailing Address - City:CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01824
Mailing Address - Country:US
Mailing Address - Phone:401-996-5597
Mailing Address - Fax:617-241-8168
Practice Address - Street 1:4 MEETING STREET
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824
Practice Address - Country:US
Practice Address - Phone:401-996-5597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21493122300000X
RIDEN026501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIDEN02650OtherLICENSE