Provider Demographics
NPI:1689042467
Name:KEVIN D. BURGDORF DDS LLC
Entity Type:Organization
Organization Name:KEVIN D. BURGDORF DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BURGDORF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-291-9000
Mailing Address - Street 1:12266 DEPAUL DRIVE
Mailing Address - Street 2:SUITE 325
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2514
Mailing Address - Country:US
Mailing Address - Phone:314-291-9000
Mailing Address - Fax:314-291-0590
Practice Address - Street 1:12266 DEPAUL DRIVE
Practice Address - Street 2:SUITE 325
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2514
Practice Address - Country:US
Practice Address - Phone:314-291-9000
Practice Address - Fax:314-291-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009008266122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty