Healthcare Provider Details

I. General information

NPI: 1700720620
Provider Name (Legal Business Name): JERSEY CITY DENTISTRY PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 GLENWOOD AVE
JERSEY CITY NJ
07306-4631
US

IV. Provider business mailing address

22 GLENWOOD AVE
JERSEY CITY NJ
07306-4631
US

V. Phone/Fax

Practice location:
  • Phone: 201-333-0883
  • Fax: 201-333-3225
Mailing address:
  • Phone: 201-333-0883
  • Fax: 201-333-3225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. SRINIKETH SRINIVASA
Title or Position: PRESIDENT
Credential: DMD
Phone: 201-333-0883