MEDICARE: KENNETH BROCHIN 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	1223G0001X	General Practice Dentistry	15261	OH
2	1223G0001X	General Practice Dentistry	042386	NY

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
2	34-1389351	OTHER	OH	TAX ID #
3	01895	OTHER	OH	PARAMOUNT HEALTH CARE
4	818060	OTHER	OH	WORKERS COMP POLICY #

General Provider Information

NPI Number	:	1568527802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH BROCHIN DDS

Provider Business Mailing Address
First Line	:	4210 W CENTRAL AVE
Second Line	:
City	:	OTTAWA HILLS
State	:	OH
Zip	:	43606-2207
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	:	43606-2207
Country	:	US
Telephone Number	:	419-535-1066
Fax Number	:	419-535-1379

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

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	06/11/2009

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Directions to “ KENNETH BROCHIN DDS” Practice Location

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