Provider Demographics
NPI:1467560110
Name:WECHTERMAN, IRA P (DDS)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:P
Last Name:WECHTERMAN
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:BLDG 6 3237 ROUTE 112
Mailing Address - Street 2:SUITE 7B
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1424
Mailing Address - Country:US
Mailing Address - Phone:631-698-1140
Mailing Address - Fax:631-696-3520
Practice Address - Street 1:BLDG 6 3237 ROUTE 112
Practice Address - Street 2:SUITE 7B
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1424
Practice Address - Country:US
Practice Address - Phone:631-698-1140
Practice Address - Fax:631-696-3520
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00646960Medicaid