MEDICARE: DR. DEEPA JAYAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	053694	NY

General Provider Information

NPI Number	:	1063677953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEEPA JAYAM

Provider Business Mailing Address
First Line	:	3 PARKWAY DR
Second Line	:
City	:	ROSLYN HEIGHTS
State	:	NY
Zip	:	11577-2705
Country	:	US
Telephone Number	:	516-656-0881
Fax Number	:

Provider Business Practice Location Address
First Line	:	3 PARKWAY DR
Second Line	:
City	:	ROSLYN HEIGHTS
State	:	NY
Zip	:	11577-2705
Country	:	US
Telephone Number	:	516-656-0881
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2008
Last Update Date	:	07/21/2008

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