Provider Demographics
NPI:1023124187
Name:JETT, JOHN BENJAMIN (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BENJAMIN
Last Name:JETT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2329 DEVINE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-2431
Mailing Address - Country:US
Mailing Address - Phone:803-799-3368
Mailing Address - Fax:803-799-3504
Practice Address - Street 1:2329 DEVINE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-2431
Practice Address - Country:US
Practice Address - Phone:803-799-3368
Practice Address - Fax:803-799-3504
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ28042Medicaid