Provider Demographics
NPI:1518167014
Name:YALISOVE, EDWARD S (DMD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:S
Last Name:YALISOVE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 NORTH FRANKLIN STREET
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-4327
Mailing Address - Country:US
Mailing Address - Phone:302-658-4124
Mailing Address - Fax:302-656-0927
Practice Address - Street 1:1111 NORTH FRANKLIN STREET
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-4327
Practice Address - Country:US
Practice Address - Phone:302-658-4124
Practice Address - Fax:302-656-0927
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG100009001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice