Provider Demographics
NPI:1376641639
Name:LYON GAVRILOV, KARINA (DDS)
Entity Type:Individual
Prefix:
First Name:KARINA
Middle Name:
Last Name:LYON GAVRILOV
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 S MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-3187
Mailing Address - Country:US
Mailing Address - Phone:847-465-0800
Mailing Address - Fax:
Practice Address - Street 1:75 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-3187
Practice Address - Country:US
Practice Address - Phone:847-465-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist