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General NPI Number Information
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NPI Number | 1982217048
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Entity Type | Individual
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Provider Name | LISA CALLOWAY DJERNES DMD
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Gender | Female
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Dates
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Enumeration Date | 08/28/2020
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Last Update Date | 07/07/2022
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Provider Practice Location Address
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Address Line | 965 BATTLEFIELD PKWY
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City | FORT OGLETHORPE
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State | GA
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Zip | 30742-3945
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Country | US
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Telephone | 706-866-8412
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Fax |
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Provider Business Mailing Address
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Address Line | 824 HUNTERS POINTE LN
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City | BOWLING GREEN
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State | KY
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Zip | 42104-7211
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Country | US
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Telephone | 423-322-3191
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Fax |
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN016094
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 10710
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License Number State | KY
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