MEDICARE: DR. JYOTHI KOTIAN VASANTHA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DS0000009360	TN

General Provider Information

NPI Number	:	1538443528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JYOTHI KOTIAN VASANTHA DDS

Provider Business Mailing Address
First Line	:	1261 BRIDGETON PARK DR
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-8341
Country	:	US
Telephone Number	:	615-468-9157
Fax Number	:

Provider Business Practice Location Address
First Line	:	1261 BRIDGETON PARK DR
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-2942
Country	:	US
Telephone Number	:	615-486-9157
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2011
Last Update Date	:	03/26/2013

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