Healthcare Provider Details

I. General information

NPI: 1568527802
Provider Name (Legal Business Name): KENNETH BROCHIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 06/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 W CENTRAL AVE
OTTAWA HILLS OH
43606-2207
US

IV. Provider business mailing address

4210 W CENTRAL AVE
OTTAWA HILLS OH
43606-2207
US

V. Phone/Fax

Practice location:
  • Phone: 419-535-1066
  • Fax: 419-535-1379
Mailing address:
  • Phone: 419-535-1066
  • Fax: 419-535-1379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15261
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number042386
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: