Provider Demographics
NPI:1114471943
Name:EDWARDS, KENNETH (DMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:EDWARDS
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 1:2622 S 13TH ST
Mailing Address - Street 2:FRNT
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-1804
Mailing Address - Country:US
Mailing Address - Phone:314-309-4494
Mailing Address - Fax:
Practice Address - Street 1:1205 NE CORONADO DR
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2928
Practice Address - Country:US
Practice Address - Phone:816-228-4090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160062511223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral Practice