Provider Demographics
NPI:1447392394
Name:DOMOZYCH, RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:DOMOZYCH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 CONNETQUOT RD
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-2146
Mailing Address - Country:US
Mailing Address - Phone:631-244-8516
Mailing Address - Fax:631-277-4849
Practice Address - Street 1:127 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730
Practice Address - Country:US
Practice Address - Phone:631-277-4848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046327122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01627476Medicaid