Provider Demographics
NPI:1639567811
Name:KENNETH B. SCROGGINS, D.M.D., LLC
Entity Type:Organization
Organization Name:KENNETH B. SCROGGINS, D.M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:B
Authorized Official - Last Name:SCROGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:314-965-3500
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110219231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty