Healthcare Provider Details

I. General information

NPI: 1992707152
Provider Name (Legal Business Name): KENNETH MARC GEWANT D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 BUCKNELL DR
PLAINVIEW NY
11803-1802
US

IV. Provider business mailing address

20 BUCKNELL DR
PLAINVIEW NY
11803-1802
US

V. Phone/Fax

Practice location:
  • Phone: 516-376-5442
  • Fax:
Mailing address:
  • Phone: 516-376-5442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number036102
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: