Provider Demographics
NPI:1477244564
Name:ILYASOV, MICHAEL M
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:ILYASOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:M
Other - Last Name:ILYASOV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:823 W JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:823 W JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3216
Practice Address - Country:US
Practice Address - Phone:631-543-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2024-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0643101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice