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General NPI Number Information
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NPI Number | 1235837147
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Entity Type | Individual
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Provider Name | WYATT AUSTIN RICHTER
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Gender | Male
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Dates
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Enumeration Date | 02/20/2023
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Last Update Date | 09/11/2024
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Provider Practice Location Address
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Address Line | 680 S COUNTRY RD
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City | EAST PATCHOGUE
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State | NY
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Zip | 11772-5551
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Country | US
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Telephone | 631-475-1191
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Fax |
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Provider Business Mailing Address
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Address Line | SUNY AT STONY BROOK, DEPARTMENT OF HOSPITAL DENTISTRY WESTCHESTER HALL, ROOM 151
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City | STONY BROOK
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State | NY
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Zip | 11794-8711
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Country | US
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Telephone | 631-444-2557
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Fax | 631-444-6013
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 064164
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License Number State | NY
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