Provider Demographics
NPI:1134399421
Name:DR.KENBROSHDDSPC
Entity type:Organization
Organization Name:DR.KENBROSHDDSPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:DR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:BROSH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:618-566-7000
Mailing Address - Street 1:1180 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-1178
Mailing Address - Country:US
Mailing Address - Phone:618-566-7000
Mailing Address - Fax:618-566-7000
Practice Address - Street 1:1180 N 6TH ST
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-1178
Practice Address - Country:US
Practice Address - Phone:618-566-7000
Practice Address - Fax:618-566-7000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019019341305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service