MEDICARE: KENNETH BROCHIN, D.D.S., LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	15261	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447626049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNETH BROCHIN, D.D.S., LLC

Provider Business Mailing Address
First Line	:	4210 W CENTRAL AVE
Second Line	:
City	:	OTTAWA HILLS
State	:	OH
Zip	:	43606-2270
Country	:	US
Telephone Number	:	419-535-1066
Fax Number	:	419-535-1379

Provider Business Practice Location Address
First Line	:	4210 W CENTRAL AVE
Second Line	:
City	:	OTTAWA HILLS
State	:	OH
Zip	:	43606-2270
Country	:	US
Telephone Number	:	419-535-1066
Fax Number	:	419-535-1379

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DEBORAH S DETTERMAN
Credential	:
Telephone Number	:	419-535-1066

Provider Enumeration Date	:	08/18/2015
Last Update Date	:	08/18/2015

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