MEDICARE: JETT AND SELLERS PC

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	S011456-3	VA

General Provider Information

NPI Number	:	1891852307
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JETT AND SELLERS PC

Provider Business Mailing Address
First Line	:	3116 TYRE NECK RD
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-4512
Country	:	US
Telephone Number	:	757-483-2110
Fax Number	:	757-686-0679

Provider Business Practice Location Address
First Line	:	3116 TYRE NECK RD
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-4512
Country	:	US
Telephone Number	:	757-483-2110
Fax Number	:	757-686-0679

Authorized Official
Title or Position	:	OFFICE MGR
Name	:	MRS. EDITH M DODD
Credential	:
Telephone Number	:	757-483-2110

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	11/12/2013

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