Provider Demographics
NPI:1982217048
Name:DJERNES, LISA CALLOWAY (DMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CALLOWAY
Last Name:DJERNES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 HUNTERS POINTE LN
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-7211
Mailing Address - Country:US
Mailing Address - Phone:423-322-3191
Mailing Address - Fax:
Practice Address - Street 1:965 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3945
Practice Address - Country:US
Practice Address - Phone:706-866-8412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0160941223G0001X
KY10710122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice