Provider Demographics
NPI:1881612810
Name:WYLES, BRUCE KEVIN (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:KEVIN
Last Name:WYLES
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 1:134 D LADYS ISLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29907
Mailing Address - Country:US
Mailing Address - Phone:843-838-1431
Mailing Address - Fax:843-522-9931
Practice Address - Street 1:134 D LADYS ISLAND DRIVE
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29907
Practice Address - Country:US
Practice Address - Phone:843-838-1431
Practice Address - Fax:843-522-9931
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC570758246Medicare UPIN