Provider Demographics
NPI:1265507586
Name:JERNIGAN, KIM UNDERWOOD (DMD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:UNDERWOOD
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3298 SUMMIT BLVD
Mailing Address - Street 2:#10
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503
Mailing Address - Country:US
Mailing Address - Phone:850-434-5247
Mailing Address - Fax:850-433-1530
Practice Address - Street 1:3298 SUMMIT BLVD
Practice Address - Street 2:#10
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503
Practice Address - Country:US
Practice Address - Phone:850-434-5247
Practice Address - Fax:850-433-1530
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN145971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice