Provider Demographics
NPI:1104139385
Name:MCKETA, NATHAN (DMD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:MCKETA
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 1:3435 SALTERBECK ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7117
Mailing Address - Country:US
Mailing Address - Phone:843-971-6864
Mailing Address - Fax:843-971-6501
Practice Address - Street 1:3435 SALTERBECK ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7117
Practice Address - Country:US
Practice Address - Phone:843-971-6864
Practice Address - Fax:843-971-6501
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4678122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist