Provider Demographics
NPI:1700309127
Name:WYCLIFFE, LOREDANA BANU (DMD)
Entity Type:Individual
Prefix:
First Name:LOREDANA
Middle Name:BANU
Last Name:WYCLIFFE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3310
Mailing Address - Country:US
Mailing Address - Phone:501-483-3939
Mailing Address - Fax:
Practice Address - Street 1:216 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3418
Practice Address - Country:US
Practice Address - Phone:501-315-1512
Practice Address - Fax:501-315-6657
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4206122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist