=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003399882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTIUM DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2018
-----------------------------------------------------
Last Update Date | 09/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 965 AVENUE C
-----------------------------------------------------
City | BAYONNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07002-3019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-339-3993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 135 MONTGOMERY ST APT 16F
-----------------------------------------------------
City | JERSEY CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07302-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-339-3993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. RESHMA SHETTY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 732-979-8008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------