Provider Demographics
NPI:1790126761
Name:JERNIGAN, JOHN C (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
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 1:1427 N WESLEYAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-1843
Mailing Address - Country:US
Mailing Address - Phone:252-977-7197
Mailing Address - Fax:252-977-6756
Practice Address - Street 1:1427 N WESLEYAN BLVD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-1843
Practice Address - Country:US
Practice Address - Phone:252-977-7197
Practice Address - Fax:252-977-6756
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice