Provider Demographics
NPI:1356564512
Name:SMITH, WYATT L (DDS)
Entity type:Individual
Prefix:DR
First Name:WYATT
Middle Name:L
Last Name:SMITH
Suffix:
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 1:5010 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-4606
Mailing Address - Country:US
Mailing Address - Phone:219-887-6053
Mailing Address - Fax:219-887-3626
Practice Address - Street 1:5010 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-4606
Practice Address - Country:US
Practice Address - Phone:219-887-6053
Practice Address - Fax:219-887-3626
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN81471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice