Healthcare Provider Details

I. General information

NPI: 1982217048
Provider Name (Legal Business Name): LISA CALLOWAY DJERNES DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 BATTLEFIELD PKWY
FORT OGLETHORPE GA
30742-3945
US

IV. Provider business mailing address

824 HUNTERS POINTE LN
BOWLING GREEN KY
42104-7211
US

V. Phone/Fax

Practice location:
  • Phone: 706-866-8412
  • Fax:
Mailing address:
  • Phone: 423-322-3191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN016094
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10710
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: