Provider Demographics
NPI:1457679342
Name:KERNODLE, DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:KERNODLE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 W PARKSIDE LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-1228
Mailing Address - Country:US
Mailing Address - Phone:800-409-2563
Mailing Address - Fax:623-321-6268
Practice Address - Street 1:708 E DIXON RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72206-4114
Practice Address - Country:US
Practice Address - Phone:877-227-9892
Practice Address - Fax:623-321-6268
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1904122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist