Provider Demographics
NPI:1881022614
Name:WYATT DENTAL ASSOCIATES
Entity type:Organization
Organization Name:WYATT DENTAL ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-501-5860
Mailing Address - Street 1:3308 S DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-7818
Mailing Address - Country:US
Mailing Address - Phone:813-830-0090
Mailing Address - Fax:813-835-0638
Practice Address - Street 1:3308 S DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-7818
Practice Address - Country:US
Practice Address - Phone:813-830-0090
Practice Address - Fax:813-835-0638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18714122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty