Provider Demographics
NPI:1427311471
Name:GULYAMOV, ILYOSS (DMD)
Entity type:Individual
Prefix:
First Name:ILYOSS
Middle Name:
Last Name:GULYAMOV
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 KIMBALL CT APT 306
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01803-3843
Mailing Address - Country:US
Mailing Address - Phone:866-942-5444
Mailing Address - Fax:
Practice Address - Street 1:311 CENTRAL ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-2341
Practice Address - Country:US
Practice Address - Phone:866-942-5444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-24
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856045122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist