Provider Demographics
NPI:1235658238
Name:MEDA, JYOTHSNA (DMD)
Entity type:Individual
Prefix:
First Name:JYOTHSNA
Middle Name:
Last Name:MEDA
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 1:1050 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2905
Mailing Address - Country:US
Mailing Address - Phone:573-426-2233
Mailing Address - Fax:573-202-2450
Practice Address - Street 1:1050 W 10TH ST STE 520
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2905
Practice Address - Country:US
Practice Address - Phone:573-426-2233
Practice Address - Fax:573-202-2450
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170313911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice