MEDICARE: DR. VICKI J WYAN DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DI 014669	NJ

General Provider Information

NPI Number	:	1124086061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VICKI J WYAN DMD

Provider Business Mailing Address
First Line	:	1060 GAFFNEY ROAD 7500
Second Line	:	USA DENTAC ALASKA FT WAINWRIGHT
City	:	FORT WAINWRIGHT
State	:	AK
Zip	:	99703-7500
Country	:	US
Telephone Number	:	907-361-5530
Fax Number	:	907-361-4859

Provider Business Practice Location Address
First Line	:	1060 GAFFNEY ROAD 7500
Second Line	:	USA DENTAC ALASKA FT WAINWRIGHT
City	:	FORT WAINWRIGHT
State	:	AK
Zip	:	99703-7500
Country	:	US
Telephone Number	:	907-361-5530
Fax Number	:	907-361-4859

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	09/22/2011

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