Provider Demographics
NPI:1265526297
Name:MUTHUSWAMY, MAYA (DMD)
Entity type:Individual
Prefix:DR
First Name:MAYA
Middle Name:
Last Name:MUTHUSWAMY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MAYA
Other - Middle Name:
Other - Last Name:NATHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 WESTGATE DR STE 2
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1810
Mailing Address - Country:US
Mailing Address - Phone:508-587-5333
Mailing Address - Fax:
Practice Address - Street 1:612 CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2552
Practice Address - Country:US
Practice Address - Phone:617-524-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA02973999Medicaid