Provider Demographics
NPI:1558055020
Name:KNECHTEL, WYATT J (DMD)
Entity Type:Individual
Prefix:DR
First Name:WYATT
Middle Name:J
Last Name:KNECHTEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 VIVIAN ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3217
Mailing Address - Country:US
Mailing Address - Phone:303-532-7088
Mailing Address - Fax:
Practice Address - Street 1:1322 VIVIAN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3217
Practice Address - Country:US
Practice Address - Phone:303-532-7088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002056601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice