=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699608109
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | E 55TH STREET DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2026
-----------------------------------------------------
Last Update Date | 06/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 E 55TH ST FL 7
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10022-4514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-741-4294
-----------------------------------------------------
Fax | 516-887-0080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 E 55TH ST FL 7
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10022-4514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-741-4294
-----------------------------------------------------
Fax | 516-887-0080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER
-----------------------------------------------------
Name | DR. IGOR ILYABAYEV
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 646-741-4294
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------