Healthcare Provider Details

I. General information

NPI: 1295775252
Provider Name (Legal Business Name): JAMES KEVIN JETTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

YUCAIPA VALLEY SPANISH SDA CHURCH 12504 4TH ST
YUCAIPA CA
92399
US

IV. Provider business mailing address

37441 IRONWOOD DR
YUCAIPA CA
92399-7024
US

V. Phone/Fax

Practice location:
  • Phone: 909-518-4133
  • Fax: 909-790-7206
Mailing address:
  • Phone: 909-518-4133
  • Fax: 909-790-7206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number33939
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: