Provider Demographics
NPI:1184038929
Name:WYATT DENTAL CORPORATION
Entity type:Organization
Organization Name:WYATT DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CHERYLIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-546-3791
Mailing Address - Street 1:1100 SONOMA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-8901
Mailing Address - Country:US
Mailing Address - Phone:707-546-3791
Mailing Address - Fax:707-546-9732
Practice Address - Street 1:1100 SONOMA AVE STE B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-8901
Practice Address - Country:US
Practice Address - Phone:707-546-3791
Practice Address - Fax:707-546-9732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58495122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty