Provider Demographics
NPI:1215011713
Name:JURGENS, CARL EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:EDWARD
Last Name:JURGENS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 W MAIN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62522
Mailing Address - Country:US
Mailing Address - Phone:217-428-4683
Mailing Address - Fax:217-428-4738
Practice Address - Street 1:334 W MAIN
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62522
Practice Address - Country:US
Practice Address - Phone:217-428-4683
Practice Address - Fax:217-428-4738
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
914070Medicare PIN
T90562Medicare UPIN