Provider Demographics
NPI:1134789241
Name:JERNIGAN, DIXIE (DMD)
Entity type:Individual
Prefix:DR
First Name:DIXIE
Middle Name:
Last Name:JERNIGAN
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 1:894 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-2374
Mailing Address - Country:US
Mailing Address - Phone:941-713-4943
Mailing Address - Fax:
Practice Address - Street 1:4140 WOODMERE PARK BLVD STE 1
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-2205
Practice Address - Country:US
Practice Address - Phone:941-493-5923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24263122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist