Provider Demographics
NPI:1154442572
Name:WYCHE, BRIAN L (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
Last Name:WYCHE
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 1:1305 EAST KIRK
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743
Mailing Address - Country:US
Mailing Address - Phone:580-326-9631
Mailing Address - Fax:580-326-5440
Practice Address - Street 1:1305 EAST KIRK
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743
Practice Address - Country:US
Practice Address - Phone:580-326-9631
Practice Address - Fax:580-326-5440
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-09-05
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-09-05
Provider Licenses
StateLicense IDTaxonomies
OK73368122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist