Provider Demographics
NPI:1578777280
Name:ROTSKOFF, KENNETH S (MD,DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:S
Last Name:ROTSKOFF
Suffix:
Gender:M
Credentials:MD,DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 S BRENTWOOD BLVD
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1223
Mailing Address - Country:US
Mailing Address - Phone:314-721-1010
Mailing Address - Fax:
Practice Address - Street 1:1034 S BRENTWOOD BLVD
Practice Address - Street 2:SUITE 1010
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1223
Practice Address - Country:US
Practice Address - Phone:314-721-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO011149204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO011149OtherDENTAL LICENSE
MO011149OtherDENTAL LICENSE