Healthcare Provider Details

I. General information

NPI: 1972280543
Provider Name (Legal Business Name): SHYAMALY PREMARAJ DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2217 KINGSLEY AVE
ORANGE PARK FL
32073-5115
US

IV. Provider business mailing address

3110 OAK ST APT 3
JACKSONVILLE FL
32205-8643
US

V. Phone/Fax

Practice location:
  • Phone: 904-272-1165
  • Fax:
Mailing address:
  • Phone: 402-802-7333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN31401
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: