Provider Demographics
NPI:1669521019
Name:BROSSEL, KENNETH LEE (DDS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:BROSSEL
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 1:1230 S 336TH
Mailing Address - Street 2:SUITE B
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6386
Mailing Address - Country:US
Mailing Address - Phone:253-661-2344
Mailing Address - Fax:253-661-2539
Practice Address - Street 1:1230 S 336TH
Practice Address - Street 2:SUITE B
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6386
Practice Address - Country:US
Practice Address - Phone:253-661-2344
Practice Address - Fax:253-661-2539
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA52281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice