Provider Demographics
NPI:1043627508
Name:WITTY, RICHARD JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:WITTY
Suffix:JR
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 1:1707 W CHARLESTON BLVD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1707 W CHARLESTON BLVD
Practice Address - Street 2:SUITE 290
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2351
Practice Address - Country:US
Practice Address - Phone:702-671-5134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLL 380 14122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist