Provider Demographics
NPI:1205817145
Name:GERNERT, ALFRED RAYMOND (DMD MS ORTHODONTICS)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:RAYMOND
Last Name:GERNERT
Suffix:
Gender:M
Credentials:DMD MS ORTHODONTICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 CRYSTAL PLACE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:LAGRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031
Mailing Address - Country:US
Mailing Address - Phone:502-222-6202
Mailing Address - Fax:
Practice Address - Street 1:604 CRYSTAL PLACE
Practice Address - Street 2:SITE 2A
Practice Address - City:LAGRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031
Practice Address - Country:US
Practice Address - Phone:502-222-6202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3961122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0008607Medicaid