Provider Demographics
NPI:1598979833
Name:JANDYAM, SUNITA (DMD)
Entity Type:Individual
Prefix:
First Name:SUNITA
Middle Name:
Last Name:JANDYAM
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 1:11 SHANNON DR
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-4464
Mailing Address - Country:US
Mailing Address - Phone:508-754-9528
Mailing Address - Fax:
Practice Address - Street 1:431 PARK AVE # B
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-1335
Practice Address - Country:US
Practice Address - Phone:508-799-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19957122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0203611Medicaid