Provider Demographics
NPI:1003951864
Name:JETER, BERNARD LAGELLE SR (DDS)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:LAGELLE
Last Name:JETER
Suffix:SR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 W. ACEQUIA AVE
Mailing Address - Street 2:#2B
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291
Mailing Address - Country:US
Mailing Address - Phone:559-739-8400
Mailing Address - Fax:559-739-8333
Practice Address - Street 1:805 W. ACEQUIA AVE
Practice Address - Street 2:#2B
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291
Practice Address - Country:US
Practice Address - Phone:559-739-8400
Practice Address - Fax:559-739-8333
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136911223G0001X
CA235231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB 23523 01OtherDENTICAL
CA862543OtherUNITED CONCORDIA