Provider Demographics
NPI:1295806461
Name:WYATT, KENNETH ROBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
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 1:9020 CHAMPION CT
Mailing Address - Street 2:
Mailing Address - City:BALL GROUND
Mailing Address - State:GA
Mailing Address - Zip Code:30107-7018
Mailing Address - Country:US
Mailing Address - Phone:770-888-3072
Mailing Address - Fax:
Practice Address - Street 1:285 ELM ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-8233
Practice Address - Country:US
Practice Address - Phone:770-887-2915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0120321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice