Provider Demographics
NPI:1730230269
Name:GATTA, CARMEN A (DMD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:A
Last Name:GATTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 ROUTE 59
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4913
Mailing Address - Country:US
Mailing Address - Phone:845-368-1677
Mailing Address - Fax:845-368-8655
Practice Address - Street 1:79 ROUTE 59
Practice Address - Street 2:SUITE 1
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4913
Practice Address - Country:US
Practice Address - Phone:845-368-1677
Practice Address - Fax:845-368-8655
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY365401223S0112X
IL12000204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU21101Medicare UPIN