Healthcare Provider Details

I. General information

NPI: 1164420675
Provider Name (Legal Business Name): GARY ROBERT JERNBERG D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 NAVAHO AVE SUITE 102
MANKATO MN
56001-4876
US

IV. Provider business mailing address

99 NAVAHO AVE SUITE 102
MANKATO MN
56001-4876
US

V. Phone/Fax

Practice location:
  • Phone: 507-345-7537
  • Fax: 507-345-7538
Mailing address:
  • Phone: 507-345-7537
  • Fax: 507-345-7538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number8671
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: