Provider Demographics
NPI:1164420675
Name:JERNBERG, GARY ROBERT (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROBERT
Last Name:JERNBERG
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN86711223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA839878OtherUNITED CONCORDIA MILITARY
MN1B005JEOtherBCBS OF MN
MN434218600Medicaid
MN199000257Medicare ID - Type Unspecified
MN434218600Medicaid