Provider Demographics
NPI:1477674299
Name:JERNIGAN, JAMES M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:M
Last Name:JERNIGAN
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 1:4807 MAPLE AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-1006
Mailing Address - Country:US
Mailing Address - Phone:214-431-3727
Mailing Address - Fax:214-635-3803
Practice Address - Street 1:4807 MAPLE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-1006
Practice Address - Country:US
Practice Address - Phone:214-431-3727
Practice Address - Fax:214-635-3803
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22494122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175923509Medicaid