Provider Demographics
NPI:1124141932
Name:ILAN, JOSHUA D
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:D
Last Name:ILAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 THIELLS MOUNT IVY RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-3020
Mailing Address - Country:US
Mailing Address - Phone:845-354-6444
Mailing Address - Fax:845-354-9189
Practice Address - Street 1:18 THIELLS MOUNT IVY RD
Practice Address - Street 2:SUITE 1
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3020
Practice Address - Country:US
Practice Address - Phone:845-354-6444
Practice Address - Fax:845-354-9189
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051103-1122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice