Healthcare Provider Details

I. General information

NPI: 1174531818
Provider Name (Legal Business Name): DANIEL DOUGLAS KERSTEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 JET STREAM DR STE 110
COLORADO SPRINGS CO
80921-3938
US

IV. Provider business mailing address

1720 JET STREAM DR STE 110
COLORADO SPRINGS CO
80921-3938
US

V. Phone/Fax

Practice location:
  • Phone: 719-488-2188
  • Fax:
Mailing address:
  • Phone: 719-488-2188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD11792
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number1460
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD11792
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDEN.00203973
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: