=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033494711
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TU DENTISTA PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2011
-----------------------------------------------------
Last Update Date | 10/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4101 ROSS AVE 300
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75204-5138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-431-3727
-----------------------------------------------------
Fax | 214-635-3803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4807 MAPLE AVE 300
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75219-1006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-431-3727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PROVIDER
-----------------------------------------------------
Name | DR. JAMES M JERNIGAN
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 214-431-3727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22494
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------