Provider Demographics
NPI:1699020743
Name:JAYANTY, AMULYA
Entity Type:Individual
Prefix:
First Name:AMULYA
Middle Name:
Last Name:JAYANTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 E BROOKLINE ST
Mailing Address - Street 2:APT 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2302
Mailing Address - Country:US
Mailing Address - Phone:312-860-7102
Mailing Address - Fax:
Practice Address - Street 1:234 ESSEX ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1549
Practice Address - Country:US
Practice Address - Phone:978-837-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856064122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist