Provider Demographics
NPI:1811980006
Name:JETER, HAROLD STEWART (DDS)
Entity type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:STEWART
Last Name:JETER
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 1:804 4TH ST E
Mailing Address - Street 2:P.O. BOX 517
Mailing Address - City:SOUTH POINT
Mailing Address - State:OH
Mailing Address - Zip Code:45680-9117
Mailing Address - Country:US
Mailing Address - Phone:740-377-2020
Mailing Address - Fax:740-377-4961
Practice Address - Street 1:804 4TH ST E
Practice Address - Street 2:
Practice Address - City:SOUTH POINT
Practice Address - State:OH
Practice Address - Zip Code:45680-9117
Practice Address - Country:US
Practice Address - Phone:740-377-2020
Practice Address - Fax:740-377-4961
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8417122300000X
OH30-02-03541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3053270Medicaid
KY7100118710Medicaid