Provider Demographics
NPI:1801051503
Name:TRACY D WYATT DDS PC
Entity type:Organization
Organization Name:TRACY D WYATT DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-242-9777
Mailing Address - Street 1:7550 W LAKE MEAD BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-1001
Mailing Address - Country:US
Mailing Address - Phone:702-242-9777
Mailing Address - Fax:
Practice Address - Street 1:7550 W LAKE MEAD BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1001
Practice Address - Country:US
Practice Address - Phone:702-242-9777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS3-1631223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty