Healthcare Provider Details

I. General information

NPI: 1659432169
Provider Name (Legal Business Name): BRETT ANDREW WYLIE RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 N TU SU LN
BISHOP CA
93514-8058
US

IV. Provider business mailing address

138 COYOTE RD
BISHOP CA
93514-9432
US

V. Phone/Fax

Practice location:
  • Phone: 760-873-3443
  • Fax: 760-873-3889
Mailing address:
  • Phone: 760-872-3080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDH10477
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: