Provider Demographics
NPI:1629052840
Name:WYCOFF, REID C (DDS)
Entity Type:Individual
Prefix:
First Name:REID
Middle Name:C
Last Name:WYCOFF
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 1:406 SCIENCE DR
Mailing Address - Street 2:STE 410
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-1068
Mailing Address - Country:US
Mailing Address - Phone:608-231-9989
Mailing Address - Fax:
Practice Address - Street 1:2811 N 90TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-5707
Practice Address - Country:US
Practice Address - Phone:402-391-0459
Practice Address - Fax:402-384-8888
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6583-151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47063287713Medicaid
NE1767815OtherUNITED CONCORDIA ID