Provider Demographics
NPI:1760637672
Name:YUSUPOV, YURIY (DDS, MD)
Entity Type:Individual
Prefix:
First Name:YURIY
Middle Name:
Last Name:YUSUPOV
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 4TH AVE STE A3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-3970
Mailing Address - Country:US
Mailing Address - Phone:718-745-0400
Mailing Address - Fax:
Practice Address - Street 1:7901 4TH AVE STE A3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3970
Practice Address - Country:US
Practice Address - Phone:718-745-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0526231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery