=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962492447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY NILS KORSNES DDS, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2005
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3D DENTAL BATTALION/US NAVAL DENTAL DENTER 3D MLG, CAMP HANSEN, UNIT 38452,
-----------------------------------------------------
City | FPO
-----------------------------------------------------
State | AP
-----------------------------------------------------
Zip | 96604-0259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 011816453085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PSC 557 BOX 3266
-----------------------------------------------------
City | FPO
-----------------------------------------------------
State | AP
-----------------------------------------------------
Zip | 96379-3266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 011816117234768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 2901015048
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------