Provider Demographics
NPI:1437412988
Name:KUDASOMANNAVAR, JYOTHI G (DMD)
Entity Type:Individual
Prefix:DR
First Name:JYOTHI
Middle Name:G
Last Name:KUDASOMANNAVAR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20293 E BELLEVIEW PL
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-5226
Mailing Address - Country:US
Mailing Address - Phone:614-519-1190
Mailing Address - Fax:
Practice Address - Street 1:10371 PARKGLENN WAY STE 250
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-3871
Practice Address - Country:US
Practice Address - Phone:303-840-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0237761223G0001X
CODEN.002027951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0066756Medicaid