# LARISA ILYUTOVICH DDS PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1609954064
- **Authorized official:** MRS. LARISA ILYUTOVICH DDS (PRESIDENT OWNER)
- **Authorized official phone:** (201) 346-4660

## Contact information

- **Practice address:** 301 BRIDGE PLAZA NORTH, 2ND FLR, FORT LEE, NJ 07024
- **Practice address phone:** (201) 346-4660
- **Practice address fax:** (201) 346-1116
- **Mailing address:** 301 BRIDGE PLAZA NORTH, 2ND FLR, FORT LEE, NJ 07024
- **Mailing address phone:** (201) 346-4660
- **Mailing address fax:** (201) 346-1116

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | DI020299 | NJ | Yes |

## Other

- **Enumeration date:** 11/02/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 8797404 | — | NJ |