Healthcare Provider Details

I. General information

NPI: 1568370153
Provider Name (Legal Business Name): JAY VAIKUNTAM DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 COMMERCIAL ST SE
SALEM OR
97302-5208
US

IV. Provider business mailing address

2020 COMMERCIAL ST SE
SALEM OR
97302-5208
US

V. Phone/Fax

Practice location:
  • Phone: 503-364-7545
  • Fax: 503-540-7911
Mailing address:
  • Phone: 503-364-7545
  • Fax: 503-540-7911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CASSANDRA WIETH
Title or Position: DIRECTOR OF PAYER RELATIONS
Credential:
Phone: 623-267-8121