Kenneth Clark Priddy, DDS

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

2021048521 Issued in MO

Practice address

853 Medical Dr Ste 115
Wentzville, MO 63385-3825

Phone

(636) 887-3100

Fax

(636) 887-3102

NPI assigned

Mar 28, 2016

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in KY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: kpriddy17632@ukhcdirect.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• David M Ivey DDS PC

  • Oral & Maxillofacial Surgery (D.M.D.)
  • Saint Peters, MO
  • NPI 1912019290
  NPD
• Missouri Center for Oral Surgery and Implants LLC

  dba First Capitol Oral and Maxillofacial Surgery

  • Oral and Maxillofacial Surgery (Dentist)
  • Wentzville, MO
  • NPI 1447962915
  NPD
• Missouri Center for Oral Surgery and Implants LLC

  dba First Capitol Oral and Maxillofacial Surgery

  • Oral and Maxillofacial Surgery (Dentist)
  • Saint Peters, MO
  • NPI 1801508379
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1459123200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1656374400000",
    "number": "1598127672",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 MID RIVERS MALL DR STE 310",
            "city": "SAINT PETERS",
            "state": "MO",
            "postal_code": "633764323",
            "telephone_number": "636-928-7217",
            "fax_number": "636-397-0223"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "853 MEDICAL DR STE 115",
            "city": "WENTZVILLE",
            "state": "MO",
            "postal_code": "633853825",
            "telephone_number": "636-887-3100",
            "fax_number": "636-887-3102"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1 Mid Rivers Mall Dr Ste 310",
            "address_purpose": "LOCATION",
            "city": "Saint Peters",
            "state": "MO",
            "postal_code": "633764323",
            "country_code": "US",
            "telephone_number": "636-928-7217",
            "fax_number": "636-397-0223",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PRIDDY",
        "first_name": "KENNETH",
        "middle_name": "CLARK",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-03-28",
        "last_updated": "2022-06-28",
        "certification_date": "2022-06-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "MO",
            "license": "2021048521",
            "primary": true
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "KY",
            "license": "9781",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Premier Surgical Assisting, LLC
• Dawn Marie Prentice, LCSW
• Laura Price-Bourisaw, D.C.
• James A. Price, LPC
• Leslie Albert Price, RPH
• Primary Care Physicians, PC
• Meghan Prinster, OT
• Malia Lim Pritchett, PT, DPT
• Prorehab, PC (Athletico Physical Therapy)
• Alena Pruemer, DPT

• Oral and Maxillofacial Surgery (Dentist) in Wentzville, MO
• Providers in Wentzville, MO by specialty
• Oral and Maxillofacial Surgery (Dentist) in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 28, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.