Provider Demographics
NPI:1831313907
Name:NOVIKOV, ILLYA Y (DOCTOR OF DENTISTRY)
Entity Type:Individual
Prefix:DR
First Name:ILLYA
Middle Name:Y
Last Name:NOVIKOV
Suffix:
Gender:M
Credentials:DOCTOR OF DENTISTRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17105 SAN CARLOS BLVD
Mailing Address - Street 2:SUITE B-3
Mailing Address - City:FORT MYERS BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33931-5336
Mailing Address - Country:US
Mailing Address - Phone:239-466-2888
Mailing Address - Fax:239-466-6010
Practice Address - Street 1:17105 SAN CARLOS BLVD
Practice Address - Street 2:SUITE B-3
Practice Address - City:FORT MYERS BEACH
Practice Address - State:FL
Practice Address - Zip Code:33931-5336
Practice Address - Country:US
Practice Address - Phone:239-466-2888
Practice Address - Fax:239-466-6010
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN158521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice