Provider Demographics
NPI:1659432169
Name:WYLIE, BRETT ANDREW (RDH)
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:ANDREW
Last Name:WYLIE
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 COYOTE RD
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-9432
Mailing Address - Country:US
Mailing Address - Phone:760-872-3080
Mailing Address - Fax:
Practice Address - Street 1:52 N TU SU LN
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-8058
Practice Address - Country:US
Practice Address - Phone:760-873-3443
Practice Address - Fax:760-873-3889
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH10477124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist