Provider Demographics
NPI:1144740481
Name:WYATT, GRAYDON DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:GRAYDON
Middle Name:DOUGLAS
Last Name:WYATT
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 1:5828 ARBORLAWN DR APT 1248
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-3255
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2750 HORNE STREET
Practice Address - Street 2:#120
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-310-2024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX330731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty