MEDICARE: DR. SHAMUEL ILYAYEV DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1063034445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHAMUEL ILYAYEV DDS

Provider Business Mailing Address
First Line	:	10524 67TH AVE APT 3B
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-2128
Country	:	US
Telephone Number	:	917-291-4733
Fax Number	:

Provider Business Practice Location Address
First Line	:	10524 67TH AVE APT 3B
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-2128
Country	:	US
Telephone Number	:	917-291-4733
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2020
Last Update Date	:	05/08/2020

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