Provider Demographics
NPI:1780741397
Name:RICHERT, KENNETH DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DAVID
Last Name:RICHERT
Suffix:
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 1:547 NORTH AVE
Mailing Address - Street 2:PO BOX 58162
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15209-2305
Mailing Address - Country:US
Mailing Address - Phone:412-821-1200
Mailing Address - Fax:412-821-5588
Practice Address - Street 1:547 NORTH AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15209-2305
Practice Address - Country:US
Practice Address - Phone:412-821-1200
Practice Address - Fax:412-821-5588
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS023460L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
522299OtherUNITED CONCORDIA DENTAL I