Healthcare Provider Details

I. General information

NPI: 1235837147
Provider Name (Legal Business Name): WYATT AUSTIN RICHTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 S COUNTRY RD
EAST PATCHOGUE NY
11772-5551
US

IV. Provider business mailing address

SUNY AT STONY BROOK, DEPARTMENT OF HOSPITAL DENTISTRY WESTCHESTER HALL, ROOM 151
STONY BROOK NY
11794-8711
US

V. Phone/Fax

Practice location:
  • Phone: 631-475-1191
  • Fax:
Mailing address:
  • Phone: 631-444-2557
  • Fax: 631-444-6013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number064164
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: