Provider Demographics
NPI:1275544280
Name:WYLIE, CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:WYLIE
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 1:1589 WHEELING AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN DALE
Mailing Address - State:WV
Mailing Address - Zip Code:26038-1731
Mailing Address - Country:US
Mailing Address - Phone:304-845-2480
Mailing Address - Fax:304-845-9204
Practice Address - Street 1:1589 WHEELING AVE
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1731
Practice Address - Country:US
Practice Address - Phone:304-845-2480
Practice Address - Fax:304-845-9204
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV2926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0133399000Medicaid