Provider Demographics
NPI:1255365235
Name:WYCKOFF, CARL K III (DDS)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:K
Last Name:WYCKOFF
Suffix:III
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 1:200 E MANTUA AVE
Mailing Address - Street 2:
Mailing Address - City:WENONAH
Mailing Address - State:NJ
Mailing Address - Zip Code:08090-1921
Mailing Address - Country:US
Mailing Address - Phone:856-468-5858
Mailing Address - Fax:856-468-9098
Practice Address - Street 1:200 E MANTUA AVE
Practice Address - Street 2:
Practice Address - City:WENONAH
Practice Address - State:NJ
Practice Address - Zip Code:08090-1921
Practice Address - Country:US
Practice Address - Phone:856-468-5858
Practice Address - Fax:856-468-9098
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ117281223G0001X
NJ164171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice