Healthcare Provider Details

I. General information

NPI: 1689974156
Provider Name (Legal Business Name): ILYA BABIY RDH, MS, EPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2010
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26000 SE STARK ST
GRESHAM OR
97030-3300
US

IV. Provider business mailing address

26000 SE STARK ST
GRESHAM OR
97030-3300
US

V. Phone/Fax

Practice location:
  • Phone: 503-729-2361
  • Fax:
Mailing address:
  • Phone: 503-729-2361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH5253
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH00007943
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: