Healthcare Provider Details

I. General information

NPI: 1114194131
Provider Name (Legal Business Name): PATCHOGUE FAMILY DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 S COUNTRY RD
EAST PATCHOGUE NY
11772-5551
US

IV. Provider business mailing address

680 S COUNTRY RD
EAST PATCHOGUE NY
11772-5551
US

V. Phone/Fax

Practice location:
  • Phone: 631-475-1191
  • Fax: 631-758-5351
Mailing address:
  • Phone: 631-475-1191
  • Fax: 631-758-5351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number041854
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number050262
License Number StateNY

VIII. Authorized Official

Name: DR. RICHARD CARY RICHTER
Title or Position: PRESIDENT
Credential: DMD
Phone: 631-475-1191