Provider Demographics
NPI:1285073700
Name:JERNBERG, TIMOTHY JOHN (DMD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:JERNBERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8899 TIMBERWILDE DR STE 3
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-7896
Mailing Address - Country:US
Mailing Address - Phone:239-498-7668
Mailing Address - Fax:
Practice Address - Street 1:8899 TIMBERWILDE DR STE 3
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-7896
Practice Address - Country:US
Practice Address - Phone:239-498-7668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008752122300000X
MND133011223E0200X
FLDN274231223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist