1780901355 NPI number — WYATT DENTAL GROUP, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780901355 NPI number — WYATT DENTAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYATT DENTAL GROUP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780901355
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5037 VETERANS MEMORIAL BLVD
Provider Second Line Business Mailing Address:
STE 3E
Provider Business Mailing Address City Name:
METAIRIE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-885-1039
Provider Business Mailing Address Fax Number:
504-885-2028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5037 VETERANS MEMORIAL BLVD
Provider Second Line Business Practice Location Address:
STE 3E
Provider Business Practice Location Address City Name:
METAIRIE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70006-5136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-885-1039
Provider Business Practice Location Address Fax Number:
504-885-2028
Provider Enumeration Date:
04/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WYATT
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
504-885-1039

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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