Provider Demographics
NPI:1336286517
Name:VAIKUNTAM, JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:VAIKUNTAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 NW HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-1724
Mailing Address - Country:US
Mailing Address - Phone:541-928-1509
Mailing Address - Fax:541-928-1522
Practice Address - Street 1:155 NW HICKORY ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1724
Practice Address - Country:US
Practice Address - Phone:541-928-1509
Practice Address - Fax:541-928-1522
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD78801223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry