Provider Demographics
NPI:1689732026
Name:KERSEY, DOUGLAS BRENT JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:BRENT
Last Name:KERSEY
Suffix:JR
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 1:110 KIA DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-3731
Mailing Address - Country:US
Mailing Address - Phone:706-242-9222
Mailing Address - Fax:706-242-9220
Practice Address - Street 1:110 KIA DR
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-3731
Practice Address - Country:US
Practice Address - Phone:706-242-2222
Practice Address - Fax:706-242-9220
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0133681223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice