Provider Demographics
NPI:1851510952
Name:GARY R. JERNBERG, D.D.S., M.S.D.
Entity type:Organization
Organization Name:GARY R. JERNBERG, D.D.S., M.S.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:JERNBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MSD
Authorized Official - Phone:507-345-7537
Mailing Address - Street 1:99 NAVAHO AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4876
Mailing Address - Country:US
Mailing Address - Phone:507-345-7537
Mailing Address - Fax:507-345-7538
Practice Address - Street 1:99 NAVAHO AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4876
Practice Address - Country:US
Practice Address - Phone:507-345-7537
Practice Address - Fax:507-345-7538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1B004JEOtherBCBS OF MN