Provider Demographics
NPI:1790900892
Name:VASSERMAN, ILYA (DMD)
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:
Last Name:VASSERMAN
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 1:153 LEWIS STR
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902
Mailing Address - Country:US
Mailing Address - Phone:781-599-3553
Mailing Address - Fax:781-599-5959
Practice Address - Street 1:153 LEWIS STR
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902
Practice Address - Country:US
Practice Address - Phone:781-599-3553
Practice Address - Fax:781-599-5959
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20020122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0201421Medicaid