Provider Demographics
NPI:1164596151
Name:WYATT, ERIKA M (DDS)
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:M
Last Name:WYATT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 S COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6008
Mailing Address - Country:US
Mailing Address - Phone:480-644-9399
Mailing Address - Fax:480-668-7790
Practice Address - Street 1:86 W ESPERANZA BLVD
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-2877
Practice Address - Country:US
Practice Address - Phone:520-625-7790
Practice Address - Fax:520-399-3341
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD59911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice