Individual
LARISA ILYUTOVICH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
301 BRIDGE PLZ N, SUITE 2, FORT LEE, NJ 07024-5059
(201) 346-4660
(201) 346-1116
Mailing address
301 BRIDGE PLZ N, SUITE 2, FORT LEE, NJ 07024-5059
(201) 346-4660
(201) 346-1116
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
DI020299
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8797404
—
NJ
Enumeration date
06/06/2016
Last updated
06/06/2016
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