Provider Demographics
NPI:1083709232
Name:KERNER, MATTHEW BROOKS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:BROOKS
Last Name:KERNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MORRIS ST
Mailing Address - Street 2:#107
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1821
Mailing Address - Country:US
Mailing Address - Phone:304-344-2220
Mailing Address - Fax:304-388-2951
Practice Address - Street 1:803 PENNSYLVANIA AVE
Practice Address - Street 2:STE 302
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302
Practice Address - Country:US
Practice Address - Phone:304-388-2950
Practice Address - Fax:304-388-2951
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0160002193122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010666Medicaid
VT0160002193OtherSTATE LICENSE
WV3810009544Medicaid
VT1010666Medicaid
VT0160002193OtherSTATE LICENSE