Provider Demographics
NPI:1023007374
Name:MACK-GATES, KENYATTA (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENYATTA
Middle Name:
Last Name:MACK-GATES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KENYATTA
Other - Middle Name:MACK
Other - Last Name:TOLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:61 ORANGE PLAZA LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 ORANGE PLAZA LN
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2254
Practice Address - Country:US
Practice Address - Phone:845-344-3844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD129331223G0001X
VA04014113201223G0001X
NY048566122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02213830Medicaid
MD001746900Medicaid