Provider Demographics
NPI:1174852644
Name:JETLEY, MEENAKSHI (DMD)
Entity Type:Individual
Prefix:DR
First Name:MEENAKSHI
Middle Name:
Last Name:JETLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 NORTHFIELD AVE
Mailing Address - Street 2:SUITE #LL4
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-3026
Mailing Address - Country:US
Mailing Address - Phone:862-245-2170
Mailing Address - Fax:973-618-1558
Practice Address - Street 1:405 NORTHFIELD AVE
Practice Address - Street 2:SUITE #LL4
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-3023
Practice Address - Country:US
Practice Address - Phone:862-245-2170
Practice Address - Fax:973-618-1558
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-13
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DIO24227001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice