MEDICARE: IRINA FUZAYLOVA 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	052818	NY

General Provider Information

NPI Number	:	1720266380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRINA FUZAYLOVA DDS

Provider Business Mailing Address
First Line	:	6909 138TH ST
Second Line	:	APT#2C
City	:	FLUSHING
State	:	NY
Zip	:	11367-1603
Country	:	US
Telephone Number	:	718-490-2846
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 NASSAU AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11222-4024
Country	:	US
Telephone Number	:	718-490-2846
Fax Number	:

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

Provider Enumeration Date	:	02/06/2008
Last Update Date	:	08/24/2009

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