Provider Demographics
NPI:1205215050
Name:KELNERPERIOLLC
Entity Type:Organization
Organization Name:KELNERPERIOLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KELNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-587-6740
Mailing Address - Street 1:67 WALNUT AVE STE 307
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1687
Mailing Address - Country:US
Mailing Address - Phone:732-587-6740
Mailing Address - Fax:732-587-6741
Practice Address - Street 1:67 WALNUT AVE STE 307
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1687
Practice Address - Country:US
Practice Address - Phone:732-587-6740
Practice Address - Fax:732-587-6741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI008999001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22DI00899900OtherNJ DENTAL LICENSE