Provider Demographics
NPI:1578567301
Name:JERGINS, MICHAEL BRADLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRADLEY
Last Name:JERGINS
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 1:5628 CIRCA FISHHAWK BLVD
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-4218
Mailing Address - Country:US
Mailing Address - Phone:813-796-7668
Mailing Address - Fax:727-725-4534
Practice Address - Street 1:5628 CIRCA FISHHAWK BLVD
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-4218
Practice Address - Country:US
Practice Address - Phone:813-796-7668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN150341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice