Provider Demographics
NPI:1932866514
Name:YAKOV FUZAYLOV DENTAL PC
Entity Type:Organization
Organization Name:YAKOV FUZAYLOV DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YAKOV
Authorized Official - Middle Name:
Authorized Official - Last Name:FUZAYLOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-470-2320
Mailing Address - Street 1:7835 B SPRINGFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11364
Mailing Address - Country:US
Mailing Address - Phone:718-470-2320
Mailing Address - Fax:718-470-2320
Practice Address - Street 1:7835 B SPRINGFIELD BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11364
Practice Address - Country:US
Practice Address - Phone:718-470-2320
Practice Address - Fax:718-470-2321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03271583Medicaid