Provider Demographics
NPI:1538330089
Name:KERNAN ORAL MAXILLOFACIAL & IMPLANT SURGERY
Entity Type:Organization
Organization Name:KERNAN ORAL MAXILLOFACIAL & IMPLANT SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT ORAL MAXILLOFACIAL SURGEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:KERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-885-7204
Mailing Address - Street 1:9995 DAYTON LEBANON PIKE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458
Mailing Address - Country:US
Mailing Address - Phone:937-885-7204
Mailing Address - Fax:937-885-7206
Practice Address - Street 1:9995 DAYTON LEBANON PIKE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458
Practice Address - Country:US
Practice Address - Phone:937-885-7204
Practice Address - Fax:937-885-7206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH185181223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0666060Medicaid
OHKE4118162OtherMEDICARE INDIVIDUAL
OHKE9357911OtherMEDICARE GROUP