MEDICARE: MR. IDAN YEHEZKEL LAVIAN 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	122300000X	Dentist	063346	NY

General Provider Information

NPI Number	:	1508508540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IDAN YEHEZKEL LAVIAN DDS

Provider Business Mailing Address
First Line	:	600 W 239TH ST APT 3M
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-1268
Country	:	US
Telephone Number	:	516-305-7713
Fax Number	:

Provider Business Practice Location Address
First Line	:	3800 INDEPENDENCE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-1433
Country	:	US
Telephone Number	:	914-559-7757
Fax Number	:

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

Provider Enumeration Date	:	04/11/2022
Last Update Date	:	03/15/2026

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