Provider Demographics
NPI:1740282748
Name:JETER, THOMAS S (MD, DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:S
Last Name:JETER
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 W HARRIS AVE STE 2
Mailing Address - Street 2:P O BOX 3602
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-6377
Mailing Address - Country:US
Mailing Address - Phone:325-658-6519
Mailing Address - Fax:325-658-6510
Practice Address - Street 1:303 W HARRIS AVE
Practice Address - Street 2:STE 2
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-6377
Practice Address - Country:US
Practice Address - Phone:325-658-6519
Practice Address - Fax:325-658-6510
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX96021223S0112X
TXF1680204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
00T570OtherBCBS
B23762Medicare UPIN
00T570OtherBCBS