Healthcare Provider Details

I. General information

NPI: 1922084722
Provider Name (Legal Business Name): JOHN WAYNE KERSEY JR. D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/26/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 MDG UNIT 3215 RAMSTEIN AB
APO AE
09094-9994
US

IV. Provider business mailing address

86 MDG UNIT 3215 RAMSTEIN AB
APO AE
09094-9994
US

V. Phone/Fax

Practice location:
  • Phone: 11-496-3714
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901016002
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901016002
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2901016002
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: