Active NPI
Larisa Ilyutovich
- General Practice Dentistry
- Fort Lee, NJ
National Provider Identifier
1780033225
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- DI020299
- Practice address
- 301 Bridge PLZ N
Suite 2
Fort Lee, NJ 07024-5059 - Phone
- (201) 346-4660
- Fax
- (201) 346-1116
- NPI assigned
- Jun 6, 2016
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | DI020299 | NJ | Primary |
Addresses
Primary practice location
301 Bridge PLZ N
Suite 2
Fort Lee, NJ 07024-5059
Mailing address
301 Bridge PLZ N
Suite 2
Fort Lee, NJ 07024-5059
Phone (201) 346-4660
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 8797404 | Medicaid | NJ |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DI020299 | NJ | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Larisa Ilyutovich DDS PC | General Practice | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- General Practice Dentistry
- Fort Lee, NJ
- NPI 1609954064
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1465171200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1465171200000",
"number": "1780033225",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "301 BRIDGE PLZ N",
"address_2": "SUITE 2",
"city": "FORT LEE",
"state": "NJ",
"postal_code": "070245059",
"telephone_number": "201-346-4660",
"fax_number": "201-346-1116"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "301 BRIDGE PLZ N",
"address_2": "SUITE 2",
"city": "FORT LEE",
"state": "NJ",
"postal_code": "070245059",
"telephone_number": "201-346-4660",
"fax_number": "201-346-1116"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ILYUTOVICH",
"first_name": "LARISA",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2016-06-06",
"last_updated": "2016-06-06",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "NJ",
"license": "DI020299",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "8797404",
"state": "NJ"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fort Lee, NJ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 6, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.