Provider Demographics
NPI:1992534044
Name:GATES, DENTRAVIOUS
Entity type:Individual
Prefix:
First Name:DENTRAVIOUS
Middle Name:
Last Name:GATES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 HILL TOP HTS
Mailing Address - Street 2:
Mailing Address - City:BALDWYN
Mailing Address - State:MS
Mailing Address - Zip Code:38824-9783
Mailing Address - Country:US
Mailing Address - Phone:662-216-6672
Mailing Address - Fax:
Practice Address - Street 1:220 HILL TOP HTS
Practice Address - Street 2:
Practice Address - City:BALDWYN
Practice Address - State:MS
Practice Address - Zip Code:38824-9783
Practice Address - Country:US
Practice Address - Phone:662-216-6672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS6841208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation