Provider Demographics
NPI:1811910250
Name:KENNERLY DENTAL GROUP, INC.
Entity type:Organization
Organization Name:KENNERLY DENTAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:SCHERTZER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-842-5177
Mailing Address - Street 1:9906 KENNERLY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2704
Mailing Address - Country:US
Mailing Address - Phone:314-842-5177
Mailing Address - Fax:314-842-9935
Practice Address - Street 1:9906 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2704
Practice Address - Country:US
Practice Address - Phone:314-842-5177
Practice Address - Fax:314-842-9935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0123781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty