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General NPI Number Information
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NPI Number | 1205215050
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Entity Type | Organization
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Legal Business Name | KELNERPERIOLLC
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Dates
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Enumeration Date | 05/27/2015
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Last Update Date | 05/27/2015
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Provider Practice Location Address
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Address Line | 67 WALNUT AVE STE 307
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City | CLARK
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State | NJ
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Zip | 07066-1687
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Country | US
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Telephone | 732-587-6740
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Fax | 732-587-6741
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Provider Business Mailing Address
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Address Line | 67 WALNUT AVE STE 307
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City | CLARK
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State | NJ
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Zip | 07066-1687
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Country | US
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Telephone | 732-587-6740
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Fax | 732-587-6741
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Authorized Official
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Title or Position | PARTNER OWNER
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Name | DR. RICHARD MICHAEL KELNER
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Credential | DMD
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Telephone | 732-587-6740
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 22DI00899900
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License Number State | NJ
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