Provider Demographics
NPI:1225102007
Name:WACHUK, KENNETH JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAMES
Last Name:WACHUK
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 1:185 BROAD ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-4763
Mailing Address - Country:US
Mailing Address - Phone:203-878-1173
Mailing Address - Fax:203-874-1076
Practice Address - Street 1:185 BROAD ST
Practice Address - Street 2:SUITE C
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-4763
Practice Address - Country:US
Practice Address - Phone:203-878-1173
Practice Address - Fax:203-874-1076
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT46071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT020004607CT01OtherANTHEM BCBS
CT020004607CT01OtherANTHEM BCBS