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General NPI Number Information
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NPI Number | 1134399421
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Entity Type | Organization
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Legal Business Name | DR.KENBROSHDDSPC
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Dates
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Enumeration Date | 03/03/2008
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Last Update Date | 03/03/2008
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Provider Practice Location Address
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Address Line | 1180 N 6TH ST
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City | MASCOUTAH
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State | IL
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Zip | 62258-1178
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Country | US
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Telephone | 618-566-7000
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Fax | 618-566-7000
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Provider Business Mailing Address
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Address Line | 1180 N 6TH ST
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City | MASCOUTAH
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State | IL
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Zip | 62258-1178
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Country | US
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Telephone | 618-566-7000
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Fax | 618-566-7000
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Authorized Official
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Title or Position | PRES.
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Name | DR. KEN NEAL BROSH
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Credential | DDS
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Telephone | 618-566-7000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 019019341
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License Number State | IL
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