Provider Demographics
NPI:1194178681
Name:JETHWANI, JITENDRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JITENDRA
Middle Name:
Last Name:JETHWANI
Suffix:
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 1:520 N 12TH ST
Mailing Address - Street 2:LYONS DENTAL BUILDING, 4 TH FLOOR, ROOM 406,SUITE 456
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-0566
Mailing Address - Country:US
Mailing Address - Phone:804-828-2977
Mailing Address - Fax:804-828-3159
Practice Address - Street 1:520 N 12TH ST
Practice Address - Street 2:LYONS DENTAL BUILDING, 4 TH FLOOR, ROOM 406,SUITE 456
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-0566
Practice Address - Country:US
Practice Address - Phone:804-828-2977
Practice Address - Fax:804-828-3159
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014157921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty