Provider Demographics
NPI:1538449061
Name:SCROGGINS, KENNETH B (DMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:B
Last Name:SCROGGINS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11780 MANCHESTER RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-4600
Mailing Address - Country:US
Mailing Address - Phone:314-965-3500
Mailing Address - Fax:314-965-7721
Practice Address - Street 1:11780 MANCHESTER RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-4600
Practice Address - Country:US
Practice Address - Phone:314-965-3500
Practice Address - Fax:314-965-7721
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110219231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice