Provider Demographics
NPI:1982628103
Name:ILLES, DAVID MICHAEL (DDS,PA)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:ILLES
Suffix:
Gender:M
Credentials:DDS,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:952 AMBOY AVE
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-2810
Mailing Address - Country:US
Mailing Address - Phone:732-738-5650
Mailing Address - Fax:732-738-5650
Practice Address - Street 1:952 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-2810
Practice Address - Country:US
Practice Address - Phone:732-738-5650
Practice Address - Fax:732-738-5650
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ130981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice