Provider Demographics
NPI:1396126157
Name:JETT, KEVIN BENJAMIN (DMD)
Entity type:Individual
Prefix:MR
First Name:KEVIN
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 1:4023 FOREST DR.
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204
Mailing Address - Country:US
Mailing Address - Phone:803-782-7722
Mailing Address - Fax:803-233-6355
Practice Address - Street 1:322 WEST MAIN ST.
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072
Practice Address - Country:US
Practice Address - Phone:803-719-4187
Practice Address - Fax:803-719-4189
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8557122300000X, 390200000X
SC103011223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist
Yes1223E0200XDental ProvidersDentistEndodontics