Provider Demographics
NPI:1427212182
Name:JERNIGAN, LEO K (DMD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:K
Last Name:JERNIGAN
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:PO BOX 493
Mailing Address - Street 2:
Mailing Address - City:GULF SHORES
Mailing Address - State:AL
Mailing Address - Zip Code:36547-0493
Mailing Address - Country:US
Mailing Address - Phone:251-968-7170
Mailing Address - Fax:
Practice Address - Street 1:100 W 1ST AVE
Practice Address - Street 2:1 PROFESSIONAL PK
Practice Address - City:GULF SHORES
Practice Address - State:AL
Practice Address - Zip Code:36542-6452
Practice Address - Country:US
Practice Address - Phone:251-968-7170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL32561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice