Healthcare Provider Details

I. General information

NPI: 1194011171
Provider Name (Legal Business Name): ILYA MILOSLAVSKIY DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 06/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2364 FREDERICK DOUGLASS BLVD
NEW YORK NY
10027-3640
US

IV. Provider business mailing address

2364 FREDERICK DOUGLASS BLVD
NEW YORK NY
10027-3640
US

V. Phone/Fax

Practice location:
  • Phone: 917-658-4575
  • Fax:
Mailing address:
  • Phone: 917-658-4575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number052222
License Number StateNY

VIII. Authorized Official

Name: DR. ILYA MILOSLAVSKIY
Title or Position: PRESIDENT
Credential: DDS
Phone: 917-658-4575