Provider Demographics
NPI:1932247194
Name:JETER, TERRANCE L (DMD)
Entity Type:Individual
Prefix:DR
First Name:TERRANCE
Middle Name:L
Last Name:JETER
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 1:1770 CANDLER RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-3277
Mailing Address - Country:US
Mailing Address - Phone:404-289-2772
Mailing Address - Fax:404-289-1139
Practice Address - Street 1:1770 CANDLER RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-3277
Practice Address - Country:US
Practice Address - Phone:404-688-1350
Practice Address - Fax:404-688-2962
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN107991223G0001X
GA107991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9180930Medicaid