Provider Demographics
NPI:1598967440
Name:DOALTOWSKI, KENNETH PAUL (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PAUL
Last Name:DOALTOWSKI
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:509 EMANN DR
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-3011
Mailing Address - Country:US
Mailing Address - Phone:315-487-1270
Mailing Address - Fax:315-487-3599
Practice Address - Street 1:2105 W GENESEE ST
Practice Address - Street 2:SUITE 207
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-1656
Practice Address - Country:US
Practice Address - Phone:315-468-0031
Practice Address - Fax:315-487-3599
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032859-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00447374Medicaid