Healthcare Provider Details

I. General information

NPI: 1285073700
Provider Name (Legal Business Name): TIMOTHY JOHN JERNBERG D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8899 TIMBERWILDE DR STE 3
BONITA SPRINGS FL
34135-7896
US

IV. Provider business mailing address

8899 TIMBERWILDE DR STE 3
BONITA SPRINGS FL
34135-7896
US

V. Phone/Fax

Practice location:
  • Phone: 239-498-7668
  • Fax:
Mailing address:
  • Phone: 239-498-7668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD008752
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD13301
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN27423
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: