Provider Demographics
NPI:1619350576
Name:REICHELT, RYAN ILG (DMD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:ILG
Last Name:REICHELT
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 1:8 TULIP DR
Mailing Address - Street 2:
Mailing Address - City:LLOYD HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11743-9761
Mailing Address - Country:US
Mailing Address - Phone:631-742-1877
Mailing Address - Fax:
Practice Address - Street 1:131 NEW LONDON TPKE STE 211
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033
Practice Address - Country:US
Practice Address - Phone:860-633-0486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18581851223G0001X, 122300000X
CT119101223G0001X
NY0586921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice