Healthcare Provider Details

I. General information

NPI: 1194733097
Provider Name (Legal Business Name): GEORGE PERRY JERNIGAN II DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 PARKWOOD MEDICAL PK
ELKIN NC
28621
US

IV. Provider business mailing address

320 PARKWOOD MEDICAL PK
ELKIN NC
28621
US

V. Phone/Fax

Practice location:
  • Phone: 333-835-7113
  • Fax:
Mailing address:
  • Phone: 336-835-7113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4362
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: