Basic Information
| Provider Information | |||||||||
| NPI: | 1194873489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAYARAM | ||||||||
| FirstName: | BHAVANA | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 W 8TH ST | ||||||||
| Address2: | SUITE 810 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810033038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195624447 | ||||||||
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| Practice Location | |||||||||
| Address1: | 73C WINTHROP AVE | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018433716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787256525 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 12/28/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 21404 | MA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0204803 | 05 | MA | MEDICAID | 30303623 | 05 | NH | MEDICAID |