Provider Demographics
NPI:1649051673
Name:BROSH, KENNETH NEAL (DDS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:NEAL
Last Name:BROSH
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 1:1233 LAKE VIEW LANE
Mailing Address - Street 2:
Mailing Address - City:O'FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269
Mailing Address - Country:US
Mailing Address - Phone:618-540-5960
Mailing Address - Fax:
Practice Address - Street 1:2440 S BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-2320
Practice Address - Country:US
Practice Address - Phone:314-962-6643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020017357122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist