Provider Demographics
NPI:1235837147
Name:RICHTER, WYATT AUSTIN
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:AUSTIN
Last Name:RICHTER
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:SUNY AT STONY BROOK, DEPARTMENT OF HOSPITAL DENTISTRY
Mailing Address - Street 2:WESTCHESTER HALL, ROOM 151
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8711
Mailing Address - Country:US
Mailing Address - Phone:631-444-2557
Mailing Address - Fax:631-444-6013
Practice Address - Street 1:680 S COUNTRY RD
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-5551
Practice Address - Country:US
Practice Address - Phone:631-475-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064164122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist