Provider Demographics
NPI:1801259775
Name:JETT DENTAL, LLC
Entity type:Organization
Organization Name:JETT DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:JETT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-799-3368
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental