Provider Demographics
NPI:1083699474
Name:CHOWDHURY, JYOTI PRAKASH (BDS)
Entity Type:Individual
Prefix:
First Name:JYOTI
Middle Name:PRAKASH
Last Name:CHOWDHURY
Suffix:
Gender:M
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 E SAN MARNAN DR
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5839
Mailing Address - Country:US
Mailing Address - Phone:319-321-5075
Mailing Address - Fax:319-234-2882
Practice Address - Street 1:239 E SAN MARNAN DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5839
Practice Address - Country:US
Practice Address - Phone:319-321-5075
Practice Address - Fax:319-234-2882
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA082811223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0076372Medicaid