Provider Demographics
NPI:1477940351
Name:CHECKETTS, WYATT
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:
Last Name:CHECKETTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-2519
Mailing Address - Country:US
Mailing Address - Phone:208-201-4148
Mailing Address - Fax:
Practice Address - Street 1:N92W6920 WASHINGTON CT APT 20
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-3200
Practice Address - Country:US
Practice Address - Phone:208-201-4148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-19
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX30949122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program