Basic Information
Provider Information | |||||||||
NPI: | 1619350576 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REICHELT | ||||||||
FirstName: | RYAN | ||||||||
MiddleName: | ILG | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8 TULIP DR | ||||||||
Address2: |   | ||||||||
City: | LLOYD HARBOR | ||||||||
State: | NY | ||||||||
PostalCode: | 117439761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6317421877 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 131 NEW LONDON TPKE STE 211 | ||||||||
Address2: |   | ||||||||
City: | GLASTONBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 06033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606330486 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2015 | ||||||||
LastUpdateDate: | 02/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN1858185 | MA | N |   | Dental Providers | Dentist | General Practice | 1223G0001X | 11910 | CT | N |   | Dental Providers | Dentist | General Practice | 1223G0001X | 058692 | NY | N |   | Dental Providers | Dentist | General Practice | 122300000X | DN1858185 | MA | Y |   | Dental Providers | Dentist |   |
No ID Information.