MEDICARE: JAY SHREE KRISHNA DDD CENTER LLC

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	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1306678560
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAY SHREE KRISHNA DDD CENTER LLC

Provider Business Mailing Address
First Line	:	101 INDUSTRIAL AVE STE C
Second Line	:
City	:	LITTLE FERRY
State	:	NJ
Zip	:	07643-1936
Country	:	US
Telephone Number	:	201-870-6265
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 INDUSTRIAL AVE STE C
Second Line	:
City	:	LITTLE FERRY
State	:	NJ
Zip	:	07643-1936
Country	:	US
Telephone Number	:	201-870-6265
Fax Number	:	201-870-6263

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. PARUL SHAH
Credential	:
Telephone Number	:	201-978-5555

Provider Enumeration Date	:	08/16/2024
Last Update Date	:	08/16/2024

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