Provider Demographics
NPI:1083842660
Name:SCROGGINS, JACLYN MICHELLE (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:MICHELLE
Last Name:SCROGGINS
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:DR
Other - First Name:JACLYN
Other - Middle Name:MICHELLE
Other - Last Name:ACKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:12246 BENT SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-2117
Mailing Address - Country:US
Mailing Address - Phone:630-707-1484
Mailing Address - Fax:
Practice Address - Street 1:209 S KIRKWOOD RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-4305
Practice Address - Country:US
Practice Address - Phone:314-821-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028002122300000X
MO20120411131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist