Provider Demographics
NPI:1669506234
Name:WYSE, DAVID DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:DOUGLAS
Last Name:WYSE
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 1:207 S PROSPECT RD
Mailing Address - Street 2:STE. 2
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4905
Mailing Address - Country:US
Mailing Address - Phone:309-663-6393
Mailing Address - Fax:309-664-0366
Practice Address - Street 1:207 S PROSPECT RD
Practice Address - Street 2:STE. 2
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4905
Practice Address - Country:US
Practice Address - Phone:309-663-6393
Practice Address - Fax:309-664-0366
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice