Provider Demographics
NPI:1891902250
Name:WYLIE, THOMAS B (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:B
Last Name:WYLIE
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 1:1108 FETNER DR
Mailing Address - Street 2:P O BOX 763
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-3774
Mailing Address - Country:US
Mailing Address - Phone:229-924-4479
Mailing Address - Fax:229-924-4391
Practice Address - Street 1:1108 FETNER DR
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3774
Practice Address - Country:US
Practice Address - Phone:229-924-4479
Practice Address - Fax:229-924-4391
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0007667122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist