Provider Demographics
NPI:1447626049
Name:KENNETH BROCHIN, D.D.S., LLC
Entity type:Organization
Organization Name:KENNETH BROCHIN, D.D.S., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:S
Authorized Official - Last Name:DETTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-535-1066
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:43606-2270
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:43606-2270
Practice Address - Country:US
Practice Address - Phone:419-535-1066
Practice Address - Fax:419-535-1379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH152611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0336023Medicaid
OH0336023Medicaid