Provider Demographics
NPI:1225087364
Name:WYATT, JOHN C (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
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 1:2885 SPRING ARBOR RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3607
Mailing Address - Country:US
Mailing Address - Phone:517-787-0900
Mailing Address - Fax:517-787-6363
Practice Address - Street 1:2885 SPRING ARBOR RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-3607
Practice Address - Country:US
Practice Address - Phone:517-787-0900
Practice Address - Fax:517-787-6363
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI10935122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist