Provider Demographics
NPI:1073139937
Name:WYLIE DENTAL GROUP PLLC
Entity Type:Organization
Organization Name:WYLIE DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMEBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:XU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-662-3105
Mailing Address - Street 1:600 COOPER DR STE 140
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-3969
Mailing Address - Country:US
Mailing Address - Phone:646-662-3105
Mailing Address - Fax:
Practice Address - Street 1:600 COOPER DR STE 140
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-3969
Practice Address - Country:US
Practice Address - Phone:646-662-3105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty