Basic Information
| Provider Information | |||||||||
| NPI: | 1487851473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERNS | ||||||||
| FirstName: | ETHAN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 S ROLLIE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LUPTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806211508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032864560 | ||||||||
| FaxNumber: | 3032864589 | ||||||||
| Practice Location | |||||||||
| Address1: | 5995 IRIS PARKWAY | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038332050 | ||||||||
| FaxNumber: | 3038339183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 06/21/2016 | ||||||||
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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 | 1223G0001X | DEN.00009471 | CO | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 85757527 | 05 | CO | MEDICAID |