Healthcare Provider Details

I. General information

NPI: 1558862177
Provider Name (Legal Business Name): KS DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44A S CHESTNUT ST
BOYERTOWN PA
19512-1509
US

IV. Provider business mailing address

44A S CHESTNUT ST
BOYERTOWN PA
19512-1509
US

V. Phone/Fax

Practice location:
  • Phone: 610-367-8005
  • Fax:
Mailing address:
  • Phone: 610-367-8005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDS030108-L
License Number StatePA

VIII. Authorized Official

Name: DR. MARIE KERSHNER
Title or Position: DENTIST
Credential: DMD
Phone: 610-367-8005