Provider Demographics
NPI:1558385245
Name:AYERS, JERRY LEE JR (DMD, MHS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:AYERS
Suffix:JR
Gender:M
Credentials:DMD, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3527 BUSH RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-4805
Mailing Address - Country:US
Mailing Address - Phone:803-798-0894
Mailing Address - Fax:803-731-7887
Practice Address - Street 1:3527 BUSH RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-4805
Practice Address - Country:US
Practice Address - Phone:803-798-0894
Practice Address - Fax:803-731-7887
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26161223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX2616Medicaid