Healthcare Provider Details

I. General information

NPI: 1285808980
Provider Name (Legal Business Name): G PERRY JERNIGAN II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/15/2008
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: 336-835-7113
  • Fax: 336-835-4657
Mailing address:
  • Phone: 336-835-7113
  • Fax: 336-835-4657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. GEORGE PERRY JERNIGAN II
Title or Position: DENTIST
Credential: DDS
Phone: 336-835-7113