Provider Demographics
NPI:1780858654
Name:J.MICHAEL WYATT INC.P.C.
Entity Type:Organization
Organization Name:J.MICHAEL WYATT INC.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-842-0033
Mailing Address - Street 1:736 NW 63RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-7602
Mailing Address - Country:US
Mailing Address - Phone:405-842-0033
Mailing Address - Fax:405-842-0045
Practice Address - Street 1:736 NW 63RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-7602
Practice Address - Country:US
Practice Address - Phone:405-842-0033
Practice Address - Fax:405-842-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4910305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1134252695OtherJ.MICHAEL WYATT INC.,P.C.