Provider Demographics
NPI:1134386386
Name:JAY E. COWAN, D.D.S. PROFESSIONAL SERVICES CORPORATION
Entity type:Organization
Organization Name:JAY E. COWAN, D.D.S. PROFESSIONAL SERVICES CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:E
Authorized Official - Last Name:COWAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-536-0748
Mailing Address - Street 1:9602 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-4504
Mailing Address - Country:US
Mailing Address - Phone:317-536-0748
Mailing Address - Fax:317-536-0721
Practice Address - Street 1:9602 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-4504
Practice Address - Country:US
Practice Address - Phone:317-536-0748
Practice Address - Fax:317-536-0721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009344A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200044690Medicaid
IN300032016Medicaid