Provider Demographics
NPI:1568527802
Name:BROCHIN, KENNETH (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BROCHIN
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 1:4210 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:OTTAWA HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:43606-2207
Mailing Address - Country:US
Mailing Address - Phone:419-535-1066
Mailing Address - Fax:419-535-1379
Practice Address - Street 1:4210 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:OTTAWA HILLS
Practice Address - State:OH
Practice Address - Zip Code:43606-2207
Practice Address - Country:US
Practice Address - Phone:419-535-1066
Practice Address - Fax:419-535-1379
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH152611223G0001X
NY0423861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0336023Medicaid
OH34-1389351OtherTAX ID #
OH01895OtherPARAMOUNT HEALTH CARE
OH818060OtherWORKERS COMP POLICY #