MEDICARE: DR. KENNETH ROBERT BROCKER DDS

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	122300000X	Dentist		IL

General Provider Information

NPI Number	:	1184682791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH ROBERT BROCKER DDS

Provider Business Mailing Address
First Line	:	3135 W 111TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655
Country	:	US
Telephone Number	:	773-238-4451
Fax Number	:	773-238-9561

Provider Business Practice Location Address
First Line	:	3135 W 111TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655
Country	:	US
Telephone Number	:	773-238-4451
Fax Number	:	773-238-9561

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	07/08/2007

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