Provider Demographics
NPI:1124168687
Name:WISTON, RANDI G (DMD)
Entity type:Individual
Prefix:DR
First Name:RANDI
Middle Name:G
Last Name:WISTON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2649 STRANG BOULEVARD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598
Mailing Address - Country:US
Mailing Address - Phone:914-245-6642
Mailing Address - Fax:914-245-6728
Practice Address - Street 1:2649 STRANG BOULEVARD
Practice Address - Street 2:SUITE 202
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598
Practice Address - Country:US
Practice Address - Phone:914-245-6642
Practice Address - Fax:914-245-6728
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0414081223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U36889Medicare UPIN
D7H641Medicare ID - Type Unspecified