Provider Demographics
NPI:1326153644
Name:WYATT, ERIC WAYNE (DDS)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:WAYNE
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:PO BOX 3040
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74013
Mailing Address - Country:US
Mailing Address - Phone:918-664-1888
Mailing Address - Fax:918-664-9037
Practice Address - Street 1:5196 S YALE AVENUE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135
Practice Address - Country:US
Practice Address - Phone:918-664-1888
Practice Address - Fax:918-664-0937
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist