Provider Demographics
NPI:1750733085
Name:WYATT, JESSICA (DDS)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 N ORANGE AVE
Mailing Address - Street 2:APT 603
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-1623
Mailing Address - Country:US
Mailing Address - Phone:903-413-1648
Mailing Address - Fax:
Practice Address - Street 1:480 N ORANGE AVE
Practice Address - Street 2:APT 603
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-1623
Practice Address - Country:US
Practice Address - Phone:903-413-1648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 21891122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist