Provider Demographics
NPI:1477651545
Name:DYKE, WALLACE WYMON (DDS)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:WYMON
Last Name:DYKE
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 1:4515 POPLAR AVE
Mailing Address - Street 2:STE. 406
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-7503
Mailing Address - Country:US
Mailing Address - Phone:901-683-9800
Mailing Address - Fax:
Practice Address - Street 1:4515 POPLAR AVE
Practice Address - Street 2:STE. 406
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-7503
Practice Address - Country:US
Practice Address - Phone:901-683-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN32431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice