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General NPI Number Information
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NPI Number | 1164420675
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Entity Type | Individual
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Provider Name | GARY ROBERT JERNBERG D.D.S., M.S.D.
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Gender | Male
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Dates
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Enumeration Date | 07/08/2005
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Last Update Date | 01/28/2011
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Provider Practice Location Address
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Address Line | 99 NAVAHO AVE SUITE 102
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City | MANKATO
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State | MN
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Zip | 56001-4876
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Country | US
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Telephone | 507-345-7537
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Fax | 507-345-7538
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Provider Business Mailing Address
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Address Line | 99 NAVAHO AVE SUITE 102
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City | MANKATO
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State | MN
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Zip | 56001-4876
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Country | US
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Telephone | 507-345-7537
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Fax | 507-345-7538
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 8671
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License Number State | MN
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