Provider Demographics
NPI:1811145105
Name:WYETH, ROBERT BRYAN (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRYAN
Last Name:WYETH
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 1:1634 YORK RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918
Mailing Address - Country:US
Mailing Address - Phone:719-522-0800
Mailing Address - Fax:719-522-0810
Practice Address - Street 1:1634 YORK RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918
Practice Address - Country:US
Practice Address - Phone:719-522-0800
Practice Address - Fax:719-522-0810
Is Sole Proprietor?:No
Enumeration Date:2008-08-29
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10303122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist