Provider Demographics
NPI:1023273844
Name:R K WYATT, DMD, PC
Entity type:Organization
Organization Name:R K WYATT, DMD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:KURRY
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:256-734-1866
Mailing Address - Street 1:307 ELIZABETH ST NE
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-2937
Mailing Address - Country:US
Mailing Address - Phone:256-734-1866
Mailing Address - Fax:256-734-1869
Practice Address - Street 1:307 ELIZABETH ST NE
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-2937
Practice Address - Country:US
Practice Address - Phone:256-734-1866
Practice Address - Fax:256-734-1869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000097699Medicaid