Provider Demographics
NPI:1598127672
Name:PRIDDY, KENNETH CLARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CLARK
Last Name:PRIDDY
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:1 MID RIVERS MALL DR STE 310
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-4323
Mailing Address - Country:US
Mailing Address - Phone:636-928-7217
Mailing Address - Fax:636-397-0223
Practice Address - Street 1:853 MEDICAL DR STE 115
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3825
Practice Address - Country:US
Practice Address - Phone:636-887-3100
Practice Address - Fax:636-887-3102
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2022-06-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO20210485211223S0112X
KY97811223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery