Provider Demographics
NPI:1114065778
Name:BRODER, KENNETH N (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:N
Last Name:BRODER
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 1:144 MORGAN ST STE 5
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5433
Mailing Address - Country:US
Mailing Address - Phone:203-327-1167
Mailing Address - Fax:203-327-1168
Practice Address - Street 1:144 MORGAN ST STE 5
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5433
Practice Address - Country:US
Practice Address - Phone:203-327-1167
Practice Address - Fax:203-327-1168
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT81271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice