Provider Demographics
NPI:1912025263
Name:BAGBY, KENNETH J (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:BAGBY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 LAKE ELMO DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-1797
Mailing Address - Country:US
Mailing Address - Phone:406-252-1078
Mailing Address - Fax:406-245-8087
Practice Address - Street 1:1540 LAKE ELMO DR
Practice Address - Street 2:SUITE 3
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59105-1797
Practice Address - Country:US
Practice Address - Phone:406-252-1078
Practice Address - Fax:406-245-8087
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT16911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice