Provider Demographics
NPI:1104034909
Name:TATUM BLVD DENTISTRY, LLC
Entity Type:Organization
Organization Name:TATUM BLVD DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:602-944-0073
Mailing Address - Street 1:2323 W MESCAL ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4764
Mailing Address - Country:US
Mailing Address - Phone:602-944-0073
Mailing Address - Fax:602-944-0199
Practice Address - Street 1:11110 N TATUM BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1607
Practice Address - Country:US
Practice Address - Phone:602-977-1110
Practice Address - Fax:602-795-1420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty