Provider Demographics
NPI:1699071449
Name:DEEPA JAYAM, DMD PC
Entity type:Organization
Organization Name:DEEPA JAYAM, DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEEPA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAYAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:516-884-1654
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 1:3709 JUNCTION BLVD
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-1740
Practice Address - Country:US
Practice Address - Phone:516-884-1654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053694122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty