Provider Demographics
NPI:1447343561
Name:KERNAN, BRIAN THOMAS (DDS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:THOMAS
Last Name:KERNAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9995 DAYTON LEBANON PIKE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE FINANCE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-4231
Mailing Address - Country:US
Mailing Address - Phone:937-885-7204
Mailing Address - Fax:937-885-7206
Practice Address - Street 1:9995 DAYTON LEBANON PIKE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE FINANCE
Practice Address - State:OH
Practice Address - Zip Code:45458-4231
Practice Address - Country:US
Practice Address - Phone:937-885-7204
Practice Address - Fax:937-885-7206
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH185181223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0666060Medicaid
KE4118162Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER
OH0666060Medicaid