MEDICARE: HAL S. JETER, DDS, INC.

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710200589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAL S. JETER, DDS, INC.

Provider Business Mailing Address
First Line	:	PO BOX 517
Second Line	:
City	:	SOUTH POINT
State	:	OH
Zip	:	45680-0517
Country	:	US
Telephone Number	:	740-377-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	804 4TH ST E
Second Line	:
City	:	SOUTH POINT
State	:	OH
Zip	:	45680-9117
Country	:	US
Telephone Number	:	740-377-2020
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KELSEY DUTY
Credential	:
Telephone Number	:	740-377-2020

Provider Enumeration Date	:	03/09/2010
Last Update Date	:	06/07/2017

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