NPIMap

Organization Active NPI

Southern Minnesota Periodontics, PA

  • Periodontics
  • Mankato, MN
National Provider Identifier
1609012624
Registry record updated Dec 22, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
PeriodonticsTaxonomy code 1223P0300X
License
8671 Issued in MN
Legal business name
SOUTHERN MINNESOTA PERIODONTICS, PA
Practice address
99 Navaho Ave
Suite 102
Mankato, MN 56001-4876
Phone
(507) 345-7537
Fax
(507) 345-7538
NPI assigned
Dec 22, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 22, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Gary Jernberg
Title
Owner
Phone
(507) 345-7537

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
PeriodonticsGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 1223P0300X 8671 MN Primary
PeriodonticsGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 1223P0300X 11710 MN

Addresses

Primary practice location

99 Navaho Ave
Suite 102
Mankato, MN 56001-4876

Mailing address

99 Navaho Ave
Suite 102
Mankato, MN 56001-4876
Phone (507) 345-7537

Other identifiers 3

IdentifierTypeStateIssuer
000839878OtherPAUNITED CONCORDIA
737722300MedicaidMN
1B004JEOtherMNBCBS OF MINNESOTA

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1229904000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1229904000000",
    "number": "1609012624",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "99 NAVAHO AVE",
            "address_2": "SUITE 102",
            "city": "MANKATO",
            "state": "MN",
            "postal_code": "560014876",
            "telephone_number": "507-345-7537",
            "fax_number": "507-345-7538"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "99 NAVAHO AVE",
            "address_2": "SUITE 102",
            "city": "MANKATO",
            "state": "MN",
            "postal_code": "560014876",
            "telephone_number": "507-345-7537",
            "fax_number": "507-345-7538"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN MINNESOTA PERIODONTICS, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-12-22",
        "last_updated": "2008-12-22",
        "status": "A",
        "authorized_official_last_name": "JERNBERG",
        "authorized_official_first_name": "GARY",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "507-345-7537",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, Periodontics",
            "state": "MN",
            "license": "8671",
            "primary": true
        },
        {
            "code": "1223P0300X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, Periodontics",
            "state": "MN",
            "license": "11710",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED CONCORDIA",
            "identifier": "000839878",
            "state": "PA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "737722300",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF MINNESOTA",
            "identifier": "1B004JE",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Mankato, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.