Provider Demographics
NPI:1760364111
Name:JAYAKUMAR, SOPHANA (MDS, DDS)
Entity type:Individual
Prefix:
First Name:SOPHANA
Middle Name:
Last Name:JAYAKUMAR
Suffix:
Gender:F
Credentials:MDS, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19984 62ND PL
Mailing Address - Street 2:
Mailing Address - City:CORCORAN
Mailing Address - State:MN
Mailing Address - Zip Code:55340
Mailing Address - Country:US
Mailing Address - Phone:612-986-7544
Mailing Address - Fax:
Practice Address - Street 1:11237 FOLEY BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-3389
Practice Address - Country:US
Practice Address - Phone:763-757-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15323122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist