Healthcare Provider Details

I. General information

NPI: 1811980006
Provider Name (Legal Business Name): HAROLD STEWART JETER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 06/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 4TH ST E
SOUTH POINT OH
45680-9117
US

IV. Provider business mailing address

804 4TH ST E P.O. BOX 517
SOUTH POINT OH
45680-9117
US

V. Phone/Fax

Practice location:
  • Phone: 740-377-2020
  • Fax: 740-377-4961
Mailing address:
  • Phone: 740-377-2020
  • Fax: 740-377-4961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8417
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30-02-0354
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: