Healthcare Provider Details

I. General information

NPI: 1306068192
Provider Name (Legal Business Name): KENT KNOERNSCHILD DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH STREET, GC-4200
AUGUSTA GA
30912
US

IV. Provider business mailing address

1120 15TH STREET, GC-4200
AUGUSTA GA
30912
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-8813
  • Fax:
Mailing address:
  • Phone: 706-721-8813
  • Fax: 312-355-3864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number019020381
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDNF000429
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: