Provider Demographics
NPI:1063677953
Name:JAYAM, DEEPA
Entity type:Individual
Prefix:DR
First Name:DEEPA
Middle Name:
Last Name:JAYAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEEPA
Other - Middle Name:
Other - Last Name:JAYAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:3 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2705
Mailing Address - Country:US
Mailing Address - Phone:516-656-0881
Mailing Address - Fax:
Practice Address - Street 1:3 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-2705
Practice Address - Country:US
Practice Address - Phone:516-656-0881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0536941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice