Provider Demographics
NPI:1669166237
Name:ILICH, MARKO (DDS)
Entity type:Individual
Prefix:
First Name:MARKO
Middle Name:
Last Name:ILICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:VA
Mailing Address - Zip Code:22963-4282
Mailing Address - Country:US
Mailing Address - Phone:434-510-7261
Mailing Address - Fax:
Practice Address - Street 1:32 GARDEN LN
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:VA
Practice Address - Zip Code:22963-4282
Practice Address - Country:US
Practice Address - Phone:434-510-7261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014184811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice