Provider Demographics
NPI:1699860734
Name:GROTH, KEVIN E (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:E
Last Name:GROTH
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 1:2915 S BRENTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2713
Mailing Address - Country:US
Mailing Address - Phone:314-962-6622
Mailing Address - Fax:314-961-2288
Practice Address - Street 1:2915 S BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2713
Practice Address - Country:US
Practice Address - Phone:314-962-6622
Practice Address - Fax:314-961-2288
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0135561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice