Provider Demographics
NPI:1679687248
Name:WYATT, TODD B (DMD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:B
Last Name:WYATT
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 1:710 MARION ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4832
Mailing Address - Country:US
Mailing Address - Phone:501-268-3666
Mailing Address - Fax:501-268-0220
Practice Address - Street 1:710 MARION ST
Practice Address - Street 2:SUITE 302
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4832
Practice Address - Country:US
Practice Address - Phone:501-268-3666
Practice Address - Fax:501-268-0220
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice