Provider Demographics
NPI:1083722391
Name:WYONT, CHARLES EDWARD (DMD, PA)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDWARD
Last Name:WYONT
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 WHISKEY RD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-9090
Mailing Address - Country:US
Mailing Address - Phone:803-642-4564
Mailing Address - Fax:803-642-4515
Practice Address - Street 1:3320 WHISKEY RD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-9090
Practice Address - Country:US
Practice Address - Phone:803-642-4564
Practice Address - Fax:803-642-4515
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ20594Medicaid