Healthcare Provider Details

I. General information

NPI: 1912067604
Provider Name (Legal Business Name): ILYA B MIRONOV D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

OJH CLINIC NO 5 BURLINGTON FAMILY DENTISTRY 1250 S BURLINGTON BLVD
BURLINGTON WA
98233
US

IV. Provider business mailing address

2385 HUGHES AVE SW
SEATTLE WA
98116-1835
US

V. Phone/Fax

Practice location:
  • Phone: 360-755-5600
  • Fax:
Mailing address:
  • Phone: 206-383-7373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDE 00010565
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: