Provider Demographics
NPI:1841604832
Name:WYATT, BRADLEY D (DMD)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:D
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 1:701 INDIAN TRL STE C
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-3054
Mailing Address - Country:US
Mailing Address - Phone:254-698-0641
Mailing Address - Fax:254-698-0644
Practice Address - Street 1:701 INDIAN TRL STE C
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-3054
Practice Address - Country:US
Practice Address - Phone:254-698-0641
Practice Address - Fax:254-698-0644
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX328741223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry