MEDICARE: KENNERLY DENTAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	012378	MO

General Provider Information

NPI Number	:	1811910250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNERLY DENTAL GROUP, INC.

Provider Business Mailing Address
First Line	:	9906 KENNERLY RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2704
Country	:	US
Telephone Number	:	314-842-5177
Fax Number	:	314-842-9935

Provider Business Practice Location Address
First Line	:	9906 KENNERLY RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2704
Country	:	US
Telephone Number	:	314-842-5177
Fax Number	:	314-842-9935

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. EDWIN RICHARD SCHERTZER JR.
Credential	:	D.D.S.
Telephone Number	:	314-842-5177

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	08/22/2020

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