Provider Demographics
NPI:1609012624
Name:SOUTHERN MINNESOTA PERIODONTICS, PA
Entity Type:Organization
Organization Name:SOUTHERN MINNESOTA PERIODONTICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:JERNBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-345-7537
Mailing Address - Street 1:99 NAVAHO AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4876
Mailing Address - Country:US
Mailing Address - Phone:507-345-7537
Mailing Address - Fax:507-345-7538
Practice Address - Street 1:99 NAVAHO AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4876
Practice Address - Country:US
Practice Address - Phone:507-345-7537
Practice Address - Fax:507-345-7538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN86711223P0300X
MN117101223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000839878OtherUNITED CONCORDIA
MN737722300Medicaid
MN1B004JEOtherBCBS OF MINNESOTA