Provider Demographics
NPI:1578225611
Name:MARYA, JAYANT (DMD)
Entity type:Individual
Prefix:DR
First Name:JAYANT
Middle Name:
Last Name:MARYA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MARINA RD UNIT 401D
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-6902
Mailing Address - Country:US
Mailing Address - Phone:618-801-7554
Mailing Address - Fax:
Practice Address - Street 1:1033 ROBERTS BRANCH PKWY STE 103
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9148
Practice Address - Country:US
Practice Address - Phone:803-339-8542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC100321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice