Provider Demographics
NPI:1457645921
Name:JETHVA, AMIT R (DDS)
Entity Type:Individual
Prefix:MR
First Name:AMIT
Middle Name:R
Last Name:JETHVA
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 1:10228 BROADWAY ST.
Mailing Address - Street 2:SUITE 132
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-8089
Mailing Address - Country:US
Mailing Address - Phone:713-436-2100
Mailing Address - Fax:713-436-2933
Practice Address - Street 1:10228 BROADWAY ST.
Practice Address - Street 2:SUITE 132
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8089
Practice Address - Country:US
Practice Address - Phone:713-436-2100
Practice Address - Fax:713-436-2933
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20487122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist