=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952791006
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JERGER PEDIATRIC DENTISTRY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2015
-----------------------------------------------------
Last Update Date | 01/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 N MAIN ST
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62526-4375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-875-3080
-----------------------------------------------------
Fax | 217-875-3084
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2101 N MAIN ST
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62526-4375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-875-3080
-----------------------------------------------------
Fax | 217-875-3084
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRET M JERGER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 217-875-3080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 021001772
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------