Organization
SOUTHERN MINNESOTA PERIODONTICS, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GARY JERNBERG (OWNER)
(507) 345-7537
Entity
Organization
Contact information
Practice address
99 NAVAHO AVE, SUITE 102, MANKATO, MN 56001-4876
(507) 345-7537
(507) 345-7538
Mailing address
99 NAVAHO AVE, SUITE 102, MANKATO, MN 56001-4876
(507) 345-7537
(507) 345-7538
Taxonomy
Speciality
Code
Description
License number
State
1223P0300X
Periodontics
11710
MN
1223P0300X
Periodontics
Primary
8671
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000839878
UNITED CONCORDIA
PA
01
—
1B004JE
BCBS OF MINNESOTA
MN
05
—
737722300
—
MN
Enumeration date
12/22/2008
Last updated
12/22/2008
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