Provider Demographics
NPI:1013064260
Name:WYATT, BRAD (DMD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
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:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-0002
Mailing Address - Country:US
Mailing Address - Phone:972-727-3941
Mailing Address - Fax:972-727-4352
Practice Address - Street 1:300 W BOYD DR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-2518
Practice Address - Country:US
Practice Address - Phone:972-727-3941
Practice Address - Fax:972-727-4352
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26432122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist