Provider Demographics
NPI:1619909074
Name:MISHRA, JYOTI (DMD)
Entity Type:Individual
Prefix:
First Name:JYOTI
Middle Name:
Last Name:MISHRA
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 1:45 BUTTS STREET
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02464
Mailing Address - Country:US
Mailing Address - Phone:617-332-3950
Mailing Address - Fax:
Practice Address - Street 1:200 WEST GATE DRIVE
Practice Address - Street 2:UNITED SUITE 135
Practice Address - City:BROCKTOM
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-583-3840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20590122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist