Provider Demographics
NPI:1194701946
Name:DAMBACHER, KENNETH EUGENE (DO)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EUGENE
Last Name:DAMBACHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:YALE
Mailing Address - State:MI
Mailing Address - Zip Code:48097
Mailing Address - Country:US
Mailing Address - Phone:810-387-2175
Mailing Address - Fax:810-378-4905
Practice Address - Street 1:251 E PECK RD
Practice Address - Street 2:
Practice Address - City:PECK
Practice Address - State:MI
Practice Address - Zip Code:48466-9589
Practice Address - Country:US
Practice Address - Phone:810-378-4900
Practice Address - Fax:810-378-4905
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008768207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0857600424OtherBLUE CROSS BLUE SHIELD MI
MI9167001Medicare ID - Type Unspecified
MIE26231Medicare UPIN