Provider Demographics
NPI:1578841656
Name:FUZAILOV, EFRAIM (DDS)
Entity type:Individual
Prefix:DR
First Name:EFRAIM
Middle Name:
Last Name:FUZAILOV
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 1:608 E NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1106
Mailing Address - Country:US
Mailing Address - Phone:718-774-0144
Mailing Address - Fax:718-774-0244
Practice Address - Street 1:608 E NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1106
Practice Address - Country:US
Practice Address - Phone:718-774-0144
Practice Address - Fax:718-774-0244
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-24
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055571122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03359015Medicaid