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General NPI Number Information
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NPI Number | 1497161053
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Entity Type | Organization
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Legal Business Name | COMPLETE SMILES DENTAL PC
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Dates
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Enumeration Date | 07/03/2014
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Last Update Date | 07/03/2014
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Provider Practice Location Address
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Address Line | 6574 SAUNDERS ST APT 3E
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City | REGO PARK
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State | NY
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Zip | 11374-4240
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Country | US
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Telephone | 646-637-6997
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Fax |
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Provider Business Mailing Address
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Address Line | 7050 AUSTIN ST STE LL124A
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City | FOREST HILLS
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State | NY
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Zip | 11375-4774
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ALBERT ILYAYEV
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Credential | D.D.S.
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Telephone | 646-637-6997
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 056803
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License Number State | NY
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