Provider Demographics
NPI:1114450327
Name:O'DWYER, RITA SUSAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RITA
Middle Name:SUSAN
Last Name:O'DWYER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 143
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-0143
Mailing Address - Country:US
Mailing Address - Phone:631-760-1048
Mailing Address - Fax:
Practice Address - Street 1:2500 NESCONSET HWY BLDG 18A
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2563
Practice Address - Country:US
Practice Address - Phone:631-751-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0597721223G0001X, 1223E0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program