Provider Demographics
NPI:1912067604
Name:MIRONOV, ILYA B (DDS)
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:B
Last Name:MIRONOV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2385 HUGHES AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-1835
Mailing Address - Country:US
Mailing Address - Phone:206-383-7373
Mailing Address - Fax:
Practice Address - Street 1:OJH CLINIC NO 5 BURLINGTON FAMILY DENTISTRY
Practice Address - Street 2:1250 S BURLINGTON BLVD
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233
Practice Address - Country:US
Practice Address - Phone:360-755-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 000105651223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health