MEDICARE: DR. JERROD RYAN ODETTE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	36580	TX

General Provider Information

NPI Number	:	1396351466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERROD RYAN ODETTE DDS

Provider Business Mailing Address
First Line	:	14846 HAZEL LEAF CT
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75707-6725
Country	:	US
Telephone Number	:	903-574-0275
Fax Number	:

Provider Business Practice Location Address
First Line	:	2336 ABERDEEN DR
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-1943
Country	:	US
Telephone Number	:	903-581-1646
Fax Number	:	903-581-1646

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2020
Last Update Date	:	02/16/2026

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