Basic Information
| Provider Information | |||||||||
| NPI: | 1083709232 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERNER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | BROOKS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MORRIS ST | ||||||||
| Address2: | #107 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043442220 | ||||||||
| FaxNumber: | 3043882951 | ||||||||
| Practice Location | |||||||||
| Address1: | 803 PENNSYLVANIA AVE | ||||||||
| Address2: | STE 302 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043882950 | ||||||||
| FaxNumber: | 3043882951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 0160002193 | VT | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1010666 | 05 | VT | MEDICAID | 0160002193 | 01 | VT | STATE LICENSE | OTHER | 3810009544 | 05 | WV | MEDICAID |