Healthcare Provider Details

I. General information

NPI: 1033115506
Provider Name (Legal Business Name): PAUL GATES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 GRAND CONCOURSE
BRONX NY
10457-5524
US

IV. Provider business mailing address

1770 GRAND CONCOURSE
BRONX NY
10457-5524
US

V. Phone/Fax

Practice location:
  • Phone: 718-901-8110
  • Fax: 718-901-8121
Mailing address:
  • Phone: 718-901-8110
  • Fax: 718-901-8121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number030093-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: