Provider Demographics
NPI:1710009147
Name:JERNIGAN, BEN WALL JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:BEN
Middle Name:WALL
Last Name:JERNIGAN
Suffix:JR
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 1:315 W PONCE DE LEON AVE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2400
Mailing Address - Country:US
Mailing Address - Phone:404-378-1466
Mailing Address - Fax:
Practice Address - Street 1:315 W PONCE DE LEON AVE
Practice Address - Street 2:SUITE 340
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2400
Practice Address - Country:US
Practice Address - Phone:404-378-1466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA86121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice