Healthcare Provider Details

I. General information

NPI: 1598127672
Provider Name (Legal Business Name): KENNETH CLARK PRIDDY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

853 MEDICAL DR STE 115
WENTZVILLE MO
63385-3825
US

IV. Provider business mailing address

1 MID RIVERS MALL DR STE 310
SAINT PETERS MO
63376-4323
US

V. Phone/Fax

Practice location:
  • Phone: 636-887-3100
  • Fax: 636-887-3102
Mailing address:
  • Phone: 636-928-7217
  • Fax: 636-397-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2021048521
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9781
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: