Provider Demographics
NPI:1023097110
Name:KETAY, KENNETH R (DMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:KETAY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 MADISON AVE
Mailing Address - Street 2:STE 1704
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022
Mailing Address - Country:US
Mailing Address - Phone:212-688-3255
Mailing Address - Fax:212-758-9132
Practice Address - Street 1:509 MADISON AVE
Practice Address - Street 2:STE 1704
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022
Practice Address - Country:US
Practice Address - Phone:212-688-3255
Practice Address - Fax:212-758-9132
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist