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General NPI Number Information
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NPI Number | 1699071449
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Entity Type | Organization
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Legal Business Name | DEEPA JAYAM, DMD PC
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Dates
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Enumeration Date | 01/26/2011
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Last Update Date | 01/26/2011
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Provider Practice Location Address
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Address Line | 3709 JUNCTION BLVD
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City | CORONA
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State | NY
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Zip | 11368-1740
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Country | US
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Telephone | 516-884-1654
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Fax |
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Provider Business Mailing Address
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Address Line | 3 PARKWAY DR
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City | ROSLYN HEIGHTS
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State | NY
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Zip | 11577-2705
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Country | US
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Telephone | 516-656-0881
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DEEPA JAYAM
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Credential | DMD
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Telephone | 516-884-1654
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 053694
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License Number State | NY
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