Provider Demographics
NPI:1306132006
Name:JETER, BENJAMIN B
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:B
Last Name:JETER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7535 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29420-4211
Mailing Address - Country:US
Mailing Address - Phone:843-797-3355
Mailing Address - Fax:843-797-3641
Practice Address - Street 1:7535 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-4211
Practice Address - Country:US
Practice Address - Phone:843-797-3355
Practice Address - Fax:843-797-3641
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC70251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice