Healthcare Provider Details

I. General information

NPI: 1124168687
Provider Name (Legal Business Name): RANDI G WISTON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2649 STRANG BOULEVARD SUITE 202
YORKTOWN HEIGHTS NY
10598
US

IV. Provider business mailing address

2649 STRANG BOULEVARD SUITE 202
YORKTOWN HEIGHTS NY
10598
US

V. Phone/Fax

Practice location:
  • Phone: 914-245-6642
  • Fax: 914-245-6728
Mailing address:
  • Phone: 914-245-6642
  • Fax: 914-245-6728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number041408
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: