Provider Demographics
NPI:1942879820
Name:WYATT, DANIELA VALLE (DMD)
Entity Type:Individual
Prefix:MRS
First Name:DANIELA
Middle Name:VALLE
Last Name:WYATT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MISS
Other - First Name:DANIELA
Other - Middle Name:
Other - Last Name:SAMPAIO VALLE WYATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:119 WINDSOR ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3647
Mailing Address - Country:US
Mailing Address - Phone:617-665-3990
Mailing Address - Fax:617-665-3989
Practice Address - Street 1:119 WINDSOR ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3647
Practice Address - Country:US
Practice Address - Phone:617-665-3990
Practice Address - Fax:617-665-3989
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL14708122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist