Provider Demographics
NPI:1003399882
Name:DENTIUM DENTAL
Entity Type:Organization
Organization Name:DENTIUM DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RESHMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:732-979-8008
Mailing Address - Street 1:135 MONTGOMERY ST APT 16F
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-4628
Mailing Address - Country:US
Mailing Address - Phone:201-339-3993
Mailing Address - Fax:
Practice Address - Street 1:965 AVENUE C
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3019
Practice Address - Country:US
Practice Address - Phone:201-339-3993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-08
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0291323Medicaid