Provider Demographics
NPI:1588079370
Name:GARIBYAN, ILYA L (DMD)
Entity type:Individual
Prefix:DR
First Name:ILYA
Middle Name:L
Last Name:GARIBYAN
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 1:336 PLAZA RD N APT A
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3640
Mailing Address - Country:US
Mailing Address - Phone:617-642-1077
Mailing Address - Fax:
Practice Address - Street 1:810 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-2711
Practice Address - Country:US
Practice Address - Phone:781-662-6228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18582011223S0112X
CT011174122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist