Provider Demographics
NPI:1780033225
Name:ILYUTOVICH, LARISA
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:ILYUTOVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BRIDGE PLZ N
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-5059
Mailing Address - Country:US
Mailing Address - Phone:201-346-4660
Mailing Address - Fax:201-346-1116
Practice Address - Street 1:301 BRIDGE PLZ N
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5059
Practice Address - Country:US
Practice Address - Phone:201-346-4660
Practice Address - Fax:201-346-1116
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI0202991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8797404Medicaid