Healthcare Provider Details

I. General information

NPI: 1962492447
Provider Name (Legal Business Name): JEFFREY NILS KORSNES DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3D DENTAL BATTALION/US NAVAL DENTAL DENTER 3D MLG, CAMP HANSEN, UNIT 38452,
FPO AP
96604-0259
US

IV. Provider business mailing address

PSC 557 BOX 3266
FPO AP
96379-3266
US

V. Phone/Fax

Practice location:
  • Phone: 011816453085
  • Fax:
Mailing address:
  • Phone: 011816117234768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2901015048
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: