Healthcare Provider Details

I. General information

NPI: 1043576416
Provider Name (Legal Business Name): ILYA ZAK DDS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4537 ALAMO ST SUITE A
SIMI VALLEY CA
93063-6531
US

IV. Provider business mailing address

4537 ALAMO ST SUITE A
SIMI VALLEY CA
93063-6531
US

V. Phone/Fax

Practice location:
  • Phone: 805-520-1100
  • Fax: 805-520-9858
Mailing address:
  • Phone: 805-520-1100
  • Fax: 805-520-9858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number26453
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number46372
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number20673
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number48198
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number57513
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number38238
License Number StateCA

VIII. Authorized Official

Name: ILYA ZAK
Title or Position: OWNER, PRESIDENT
Credential: D.D.S.
Phone: 3108055201100