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General NPI Number Information
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NPI Number | 1093093585
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Entity Type | Organization
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Legal Business Name | EASY DENTAL PC
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Dates
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Enumeration Date | 08/01/2011
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Last Update Date | 10/09/2011
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Provider Practice Location Address
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Address Line | 5616 GERMANTOWN AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19144-2228
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Country | US
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Telephone | 267-335-2181
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Fax | 215-821-2327
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Provider Business Mailing Address
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Address Line | 551 ADAMS AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19120
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Country | US
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Telephone | 215-268-3344
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Fax | 215-821-2327
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Authorized Official
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Title or Position | MANAGING DIRECTOR
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Name | MR. ILYA IMYANITOV
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Credential |
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Telephone | 201-637-1357
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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