Healthcare Provider Details

I. General information

NPI: 1205817145
Provider Name (Legal Business Name): ALFRED RAYMOND GERNERT DMD MS ORTHODONTICS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 CRYSTAL PLACE SITE 2A
LAGRANGE KY
40031
US

IV. Provider business mailing address

604 CRYSTAL PLACE SUITE 2A
LAGRANGE KY
40031
US

V. Phone/Fax

Practice location:
  • Phone: 502-222-6202
  • Fax:
Mailing address:
  • Phone: 502-222-6202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3961
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: