Provider Demographics
NPI:1396351466
Name:ODETTE, JERROD RYAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JERROD
Middle Name:RYAN
Last Name:ODETTE
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 1:1909 DU BARRY LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77018-5063
Mailing Address - Country:US
Mailing Address - Phone:903-574-0275
Mailing Address - Fax:
Practice Address - Street 1:11 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4123
Practice Address - Country:US
Practice Address - Phone:281-332-7010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36580122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist