Healthcare Provider Details

I. General information

NPI: 1730371618
Provider Name (Legal Business Name): KORY MATTHEW GERNHOFER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 10/26/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 W OXFORD AVE UNIT G-1
DENVER CO
80236-3112
US

IV. Provider business mailing address

2204 KEWAUNEE CT
TRAVERSE CITY MI
49686-2000
US

V. Phone/Fax

Practice location:
  • Phone: 303-315-6150
  • Fax:
Mailing address:
  • Phone: 734-717-9252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00204919
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61274
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: